Provider Demographics
NPI:1629091236
Name:WAGMAN, MILES (MSW, LCSW, LMFT)
Entity Type:Individual
Prefix:MR
First Name:MILES
Middle Name:
Last Name:WAGMAN
Suffix:
Gender:M
Credentials:MSW, LCSW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 RECKLESS PL
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-1703
Mailing Address - Country:US
Mailing Address - Phone:732-530-7544
Mailing Address - Fax:732-530-4145
Practice Address - Street 1:41 RECKLESS PL
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-1703
Practice Address - Country:US
Practice Address - Phone:732-530-7544
Practice Address - Fax:732-530-4145
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC003653001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ637505Medicare ID - Type Unspecified