Provider Demographics
NPI:1124178835
Name:VANWAGONER, STEVEN LARRIMORE (PHD, CGP)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:LARRIMORE
Last Name:VANWAGONER
Suffix:
Gender:M
Credentials:PHD, CGP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2440 M ST NW
Mailing Address - Street 2:SUITE 429
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20037-1404
Mailing Address - Country:US
Mailing Address - Phone:202-296-5299
Mailing Address - Fax:202-223-3939
Practice Address - Street 1:2440 M ST NW
Practice Address - Street 2:SUITE 429
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20037-1404
Practice Address - Country:US
Practice Address - Phone:202-296-5299
Practice Address - Fax:202-223-3939
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPSY1813103T00000X
MD03172103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist