Provider Demographics
NPI:1124265533
Name:WACCAMAW ASSOCIATES
Entity type:Organization
Organization Name:WACCAMAW ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUDSON
Authorized Official - Middle Name:L
Authorized Official - Last Name:DUKES,JR
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:910-642-1800
Mailing Address - Street 1:PO BOX 918
Mailing Address - Street 2:
Mailing Address - City:WHITEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28472-0918
Mailing Address - Country:US
Mailing Address - Phone:910-642-1800
Mailing Address - Fax:
Practice Address - Street 1:1328 S. MADISON STREET
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472-0918
Practice Address - Country:US
Practice Address - Phone:910-642-1800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-08
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1810103TF0000X, 103TM1800X, 103TP0814X, 103TS0200X, 101Y00000X, 101YA0400X, 101YM0800X, 101YP2500X, 103TA0700X, 103TB0200X, 103TC0700X, 103TC1900X, 103TC2200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Multi-Specialty
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty
No103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysisGroup - Multi-Specialty
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & AgingGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000179Medicaid
NC2814102BMedicare PIN
NC6000179Medicaid