Provider Demographics
NPI:1346632312
Name:WAGNER, AMY R (EDD, LCSW, BCABA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:R
Last Name:WAGNER
Suffix:
Gender:F
Credentials:EDD, LCSW, BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6505 SHILOH RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-8405
Mailing Address - Country:US
Mailing Address - Phone:678-648-7644
Mailing Address - Fax:678-648-7479
Practice Address - Street 1:6505 SHILOH RD
Practice Address - Street 2:SUITE 100
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-8405
Practice Address - Country:US
Practice Address - Phone:678-648-7644
Practice Address - Fax:678-648-7479
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-26
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW004454103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst