Provider Demographics
NPI:1316014525
Name:VANWAGNER, CHARLES (DST, LMFT)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:VANWAGNER
Suffix:
Gender:M
Credentials:DST, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3733 NATIONAL DR
Mailing Address - Street 2:SUITE 221
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-4065
Mailing Address - Country:US
Mailing Address - Phone:919-783-5775
Mailing Address - Fax:919-783-5775
Practice Address - Street 1:3733 NATIONAL DR
Practice Address - Street 2:SUITE 221
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-4065
Practice Address - Country:US
Practice Address - Phone:919-783-5775
Practice Address - Fax:919-783-5775
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC192106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC84688OtherBCBS PIN#