Provider Demographics
NPI:1497120778
Name:WRAGE, LORRAINE (MED, LPC, CST)
Entity Type:Individual
Prefix:
First Name:LORRAINE
Middle Name:
Last Name:WRAGE
Suffix:
Gender:F
Credentials:MED, LPC, CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8827 GRASSY KNOLL LN
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:GA
Mailing Address - Zip Code:30527-3405
Mailing Address - Country:US
Mailing Address - Phone:770-503-6115
Mailing Address - Fax:
Practice Address - Street 1:1400 BUFORD HWY STE D1
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-8722
Practice Address - Country:US
Practice Address - Phone:770-503-6115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-11
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008665101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional