Basic Information
| Provider Information | |||||||||
| NPI: | 1699393496 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAGWELL | ||||||||
| FirstName: | ERIN | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | TCADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1351 NEWTOWN PIKE BLDG 1 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405111277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592531686 | ||||||||
| FaxNumber: | 0000000000 | ||||||||
| Practice Location | |||||||||
| Address1: | 1351 NEWTOWN PIKE | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405111275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592531686 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2020 | ||||||||
| LastUpdateDate: | 10/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 263160 | KY | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 1790731081 | 05 | KY | MEDICAID |