Provider Demographics
NPI:1740461854
Name:WAGAMAN ENTERPRISES INC
Entity type:Organization
Organization Name:WAGAMAN ENTERPRISES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:WAGAMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:360-866-7406
Mailing Address - Street 1:2100 CATON WAY SW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-1105
Mailing Address - Country:US
Mailing Address - Phone:360-866-7406
Mailing Address - Fax:360-570-3325
Practice Address - Street 1:2100 CATON WAY SW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-1105
Practice Address - Country:US
Practice Address - Phone:360-866-7406
Practice Address - Fax:360-570-3325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY 1722103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA115000170Medicare UPIN