Basic Information
| Provider Information | |||||||||
| NPI: | 1760970446 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAGGETT | ||||||||
| FirstName: | GWENDOLYN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3117 POPLARWOOD CT STE 207 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276041040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193489913 | ||||||||
| FaxNumber: | 6012494234 | ||||||||
| Practice Location | |||||||||
| Address1: | 3117 POPLARWOOD CT STE 207 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276041040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193489913 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2018 | ||||||||
| LastUpdateDate: | 03/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | P013783 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 000 | 05 | NC | MEDICAID |