Basic Information
| Provider Information | |||||||||
| NPI: | 1104009166 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAGWELL KUKOR | ||||||||
| FirstName: | MARJORIE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KUKOR | ||||||||
| OtherFirstName: | MARJORIE | ||||||||
| OtherMiddleName: | BAGWELL | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1130 VESTER AVE | ||||||||
| Address2: | SUITE C | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 455037302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373903800 | ||||||||
| FaxNumber: | 9373903804 | ||||||||
| Practice Location | |||||||||
| Address1: | 1130 VESTER AVE | ||||||||
| Address2: | SUITE C | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 455037302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373903800 | ||||||||
| FaxNumber: | 9373903804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2007 | ||||||||
| LastUpdateDate: | 09/08/2009 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 6340 | OH | N | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | PPY01684 | MO | N | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | 6340 | OH | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.