Provider Demographics
NPI:1902049547
Name:BAGLEY, RICHARD SHAWN (BCABA)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:SHAWN
Last Name:BAGLEY
Suffix:
Gender:M
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 EXECUTIVE CENTER DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-3529
Mailing Address - Country:US
Mailing Address - Phone:407-592-8489
Mailing Address - Fax:
Practice Address - Street 1:1010 EXECUTIVE CENTER DR
Practice Address - Street 2:SUITE 100
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-3529
Practice Address - Country:US
Practice Address - Phone:407-592-8489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-13
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-02-0248103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst