Provider Demographics
NPI:1528838778
Name:BAGWELL, MADISON JANEMARIE
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:JANEMARIE
Last Name:BAGWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:JANEMARIE
Other - Last Name:BONIFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:111 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-2702
Mailing Address - Country:US
Mailing Address - Phone:703-727-3139
Mailing Address - Fax:
Practice Address - Street 1:890 JOHNNIE DODDS BLVD
Practice Address - Street 2:BUILDING 3, SUITE A
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464
Practice Address - Country:US
Practice Address - Phone:843-884-3888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8680101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health