Provider Demographics
NPI:1053638031
Name:D. B. TUG WAGSTAFF, LPC
Entity Type:Organization
Organization Name:D. B. TUG WAGSTAFF, LPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUG 'TUG'
Authorized Official - Middle Name:B
Authorized Official - Last Name:WAGSTAFF
Authorized Official - Suffix:
Authorized Official - Credentials:MED, LPC
Authorized Official - Phone:801-376-4787
Mailing Address - Street 1:1021 E 70 N
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-2914
Mailing Address - Country:US
Mailing Address - Phone:801-376-4787
Mailing Address - Fax:
Practice Address - Street 1:1021 E 70 N
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-2914
Practice Address - Country:US
Practice Address - Phone:801-376-4787
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-29
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT321749-6004273R00000X, 320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT321749-6004OtherPROFESSIONAL COUNSELOR LICENSE ISSUED BY STATE OF UTAH DEPT. OF COMMERCE