Provider Demographics
NPI:1588008130
Name:G LANE WAGAMAN ED.D. PLLC
Entity Type:Organization
Organization Name:G LANE WAGAMAN ED.D. PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:G
Authorized Official - Middle Name:LANE
Authorized Official - Last Name:WAGAMAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:EDD
Authorized Official - Phone:919-803-6393
Mailing Address - Street 1:PO BOX 1424
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-3424
Mailing Address - Country:US
Mailing Address - Phone:919-803-6393
Mailing Address - Fax:919-719-0213
Practice Address - Street 1:400 KEISLER DR
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-7069
Practice Address - Country:US
Practice Address - Phone:919-803-6393
Practice Address - Fax:919-719-0213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-25
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1489103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty