Provider Demographics
NPI:1043034614
Name:WAGEMAN, AVERY (LPC)
Entity type:Individual
Prefix:
First Name:AVERY
Middle Name:
Last Name:WAGEMAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 W MCDERMOTT DR APT 515
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-3302
Mailing Address - Country:US
Mailing Address - Phone:903-421-3833
Mailing Address - Fax:
Practice Address - Street 1:1420 W MCDERMOTT DR APT 515
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-3302
Practice Address - Country:US
Practice Address - Phone:903-421-3833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-11
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX90746101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional