Provider Demographics
NPI:1457309387
Name:WAGNER, ROBERT W (LPC)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:W
Last Name:WAGNER
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 GREENCASTLE RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:TYRONE
Mailing Address - State:GA
Mailing Address - Zip Code:30290-2937
Mailing Address - Country:US
Mailing Address - Phone:770-757-7602
Mailing Address - Fax:
Practice Address - Street 1:105 GREENCASTLE RD
Practice Address - Street 2:SUITE B
Practice Address - City:TYRONE
Practice Address - State:GA
Practice Address - Zip Code:30290-2937
Practice Address - Country:US
Practice Address - Phone:770-486-1011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003153101YM0800X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional