Provider Demographics
NPI:1083908735
Name:WAGNER, MICHELE SUZANNE (CSW)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:SUZANNE
Last Name:WAGNER
Suffix:
Gender:M
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8075 MALL PKWY
Mailing Address - Street 2:STE 101-348
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-6993
Mailing Address - Country:US
Mailing Address - Phone:678-288-6550
Mailing Address - Fax:800-609-0965
Practice Address - Street 1:2900 CHAMBLEE TUCKER RD
Practice Address - Street 2:BLD 8, STE 301
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341-4100
Practice Address - Country:US
Practice Address - Phone:678-824-6590
Practice Address - Fax:678-824-6597
Is Sole Proprietor?:No
Enumeration Date:2011-05-30
Last Update Date:2011-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0042601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical