Provider Demographics
NPI:1184134553
Name:BAGLEY, WADE JAMES (LCDCI)
Entity type:Individual
Prefix:MR
First Name:WADE
Middle Name:JAMES
Last Name:BAGLEY
Suffix:
Gender:M
Credentials:LCDCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 26TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79411-1524
Mailing Address - Country:US
Mailing Address - Phone:806-780-8300
Mailing Address - Fax:806-780-8383
Practice Address - Street 1:1715 26TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79411-1524
Practice Address - Country:US
Practice Address - Phone:806-780-8300
Practice Address - Fax:806-780-8383
Is Sole Proprietor?:No
Enumeration Date:2017-10-11
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34686101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)