Basic Information
| Provider Information | |||||||||
| NPI: | 1588003123 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAGWELL | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | INEZ | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW, LADAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MILLER | ||||||||
| OtherFirstName: | MARIA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 385 CALLE DE ALEGRA STE A | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880053423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755261105 | ||||||||
| FaxNumber: | 5755244266 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 W. GRIGGS AVE | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5756472800 | ||||||||
| FaxNumber: | 5756472898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2013 | ||||||||
| LastUpdateDate: | 08/24/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TA0400X | 0115311 | NM | N | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) | 104100000X | M-08562 | NM | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | C-10108 | NM | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 52379205 | 05 | NM | MEDICAID | 620292YRND | 01 | NM | MEDICARE | OTHER |