Provider Demographics
NPI:1699854042
Name:WAGAMAN, GEORGE LANE JR (EDD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:LANE
Last Name:WAGAMAN
Suffix:JR
Gender:M
Credentials:EDD
Other - Prefix:DR
Other - First Name:G.
Other - Middle Name:LANE
Other - Last Name:WAGAMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:EDD
Mailing Address - Street 1:7332 CAPULIN CREST DR
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27539-4106
Mailing Address - Country:US
Mailing Address - Phone:919-803-6393
Mailing Address - Fax:
Practice Address - Street 1:100 EUROPA DR
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27517-2357
Practice Address - Country:US
Practice Address - Phone:919-929-1227
Practice Address - Fax:919-968-2575
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV182103TB0200X, 103T00000X, 103TC0700X, 103TC1900X, 103TF0200X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9205024000Medicaid
WV001712519OtherBCBS MTN STATE
WVCP24512Medicare PIN
WVP00169841Medicare PIN
WVCP24511Medicare PIN