Provider Demographics
NPI:1417053612
Name:WOLGAMOT, EDGAR KOBEL III (PSYD)
Entity Type:Individual
Prefix:DR
First Name:EDGAR
Middle Name:KOBEL
Last Name:WOLGAMOT
Suffix:III
Gender:M
Credentials:PSYD
Other - Prefix:DR
Other - First Name:TED
Other - Middle Name:
Other - Last Name:WOLGAMOT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:6615 N BIG HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-2451
Mailing Address - Country:US
Mailing Address - Phone:309-692-6622
Mailing Address - Fax:309-692-6952
Practice Address - Street 1:6615 N BIG HOLLOW RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-2451
Practice Address - Country:US
Practice Address - Phone:309-692-6622
Practice Address - Fax:309-692-6952
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor