Provider Demographics
NPI:1902194418
Name:BAGLEY, CYNTINA JONAE (LPC)
Entity Type:Individual
Prefix:
First Name:CYNTINA
Middle Name:JONAE
Last Name:BAGLEY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO DRAWER 248
Mailing Address - Street 2:214 BUSH RIVER DRIVE
Mailing Address - City:FARMVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23901
Mailing Address - Country:US
Mailing Address - Phone:434-392-3187
Mailing Address - Fax:434-392-9221
Practice Address - Street 1:214 BUSH RIVER DR
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901-3179
Practice Address - Country:US
Practice Address - Phone:434-392-3187
Practice Address - Fax:434-392-9221
Is Sole Proprietor?:No
Enumeration Date:2011-07-18
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701004977101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1528091063Medicaid