Provider Demographics
NPI:1083663272
Name:WAGNER, BRENDA J (PHD)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:J
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:JOY
Other - Last Name:WHITING
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5455 MERIDIAN MARK RD NE
Mailing Address - Street 2:STE 400
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342
Mailing Address - Country:US
Mailing Address - Phone:404-785-3240
Mailing Address - Fax:404-785-3600
Practice Address - Street 1:5455 MERIDIAN MARK RD NE
Practice Address - Street 2:STE 400
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:404-785-3240
Practice Address - Fax:404-785-3600
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001706103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist