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 1:2118 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:360-870-6396
Mailing Address - Fax:360-352-3289
Practice Address - Street 1:2118 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:360-352-6846
Practice Address - Fax:360-352-3289
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-31
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00002448103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent