Provider Demographics
NPI:1730747569
Name:BAGNOLI, BRENDEN C (AUD)
Entity type:Individual
Prefix:
First Name:BRENDEN
Middle Name:C
Last Name:BAGNOLI
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5755 E RIVER RD APT 3603
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85750-6729
Mailing Address - Country:US
Mailing Address - Phone:480-358-8175
Mailing Address - Fax:
Practice Address - Street 1:2600 N WYATT DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-6106
Practice Address - Country:US
Practice Address - Phone:520-324-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZDA11835231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist