Healthcare Provider Details
I. General information
NPI: 1124265533
Provider Name (Legal Business Name): WACCAMAW ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:
II. Dates (important events)
Enumeration Date: 01/08/2009
Last Update Date: 01/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:
III. Provider practice location address
1328 S. MADISON STREET
WHITEVILLE NC
28472-0918
US
IV. Provider business mailing address
PO BOX 918
WHITEVILLE NC
28472-0918
US
V. Phone/Fax
- Phone: 910-642-1800
- Fax:
- Phone: 910-642-1800
- Fax:
VI. Provider taxonomy
Scope of Practice (Provider specialty)
| # 1 | |
| Primary Taxonomy | N |
| Taxonomy Code | 103TF0000X |
| Taxonomy | Family Psychologist |
| License Number | 1810 |
| License Number State | NC |
| # 2 | |
| Primary Taxonomy | N |
| Taxonomy Code | 103TM1800X |
| Taxonomy | Intellectual & Developmental Disabilities Psychologist |
| License Number | 1810 |
| License Number State | NC |
| # 3 | |
| Primary Taxonomy | N |
| Taxonomy Code | 103TP0814X |
| Taxonomy | Psychoanalysis Psychologist |
| License Number | 1810 |
| License Number State | NC |
| # 4 | |
| Primary Taxonomy | N |
| Taxonomy Code | 103TS0200X |
| Taxonomy | School Psychologist |
| License Number | 1810 |
| License Number State | NC |
| # 5 | |
| Primary Taxonomy | N |
| Taxonomy Code | 101Y00000X |
| Taxonomy | Counselor |
| License Number | 1810 |
| License Number State | NC |
| # 6 | |
| Primary Taxonomy | N |
| Taxonomy Code | 101YA0400X |
| Taxonomy | Addiction (Substance Use Disorder) Counselor |
| License Number | 1810 |
| License Number State | NC |
| # 7 | |
| Primary Taxonomy | N |
| Taxonomy Code | 101YM0800X |
| Taxonomy | Mental Health Counselor |
| License Number | 1810 |
| License Number State | NC |
| # 8 | |
| Primary Taxonomy | N |
| Taxonomy Code | 101YP2500X |
| Taxonomy | Professional Counselor |
| License Number | 1810 |
| License Number State | NC |
| # 9 | |
| Primary Taxonomy | N |
| Taxonomy Code | 103TA0700X |
| Taxonomy | Adult Development & Aging Psychologist |
| License Number | 1810 |
| License Number State | NC |
| # 10 | |
| Primary Taxonomy | N |
| Taxonomy Code | 103TB0200X |
| Taxonomy | Cognitive & Behavioral Psychologist |
| License Number | 1810 |
| License Number State | NC |
| # 11 | |
| Primary Taxonomy | N |
| Taxonomy Code | 103TC0700X |
| Taxonomy | Clinical Psychologist |
| License Number | 1810 |
| License Number State | NC |
| # 12 | |
| Primary Taxonomy | N |
| Taxonomy Code | 103TC1900X |
| Taxonomy | Counseling Psychologist |
| License Number | 1810 |
| License Number State | NC |
| # 13 | |
| Primary Taxonomy | N |
| Taxonomy Code | 103TC2200X |
| Taxonomy | Clinical Child & Adolescent Psychologist |
| License Number | 1810 |
| License Number State | NC |
| # 14 | |
| Primary Taxonomy | Y |
| Taxonomy Code | 103T00000X |
| Taxonomy | Psychologist |
| License Number | 1810 |
| License Number State | NC |
VIII. Authorized Official
Name:
JUDSON
L
DUKES,JR
Title or Position: OWNER
Credential: PH.D
Phone: 910-642-1800
