Provider Demographics
NPI:1952467045
Name:WAGAMAN, JOEL R (PHD)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:R
Last Name:WAGAMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6334 LITTLEROCK RD SW
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512-7332
Mailing Address - Country:US
Mailing Address - Phone:360-866-7406
Mailing Address - Fax:
Practice Address - Street 1:6334 LITTLEROCK RD SW
Practice Address - Street 2:SUITE 101
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-7332
Practice Address - Country:US
Practice Address - Phone:360-866-7406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00002448103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent