Provider Demographics
NPI:1568670784
Name:WEGNER-KLEINE, MAIKE (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:MAIKE
Middle Name:
Last Name:WEGNER-KLEINE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4486 COMMERCE DR STE A
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-7505
Mailing Address - Country:US
Mailing Address - Phone:470-231-8725
Mailing Address - Fax:
Practice Address - Street 1:4486 COMMERCE DR STE A
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-7505
Practice Address - Country:US
Practice Address - Phone:470-231-8725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-20
Last Update Date:2019-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT001076106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAMFT001076OtherPROFESSIONAL LICENSE
GA11810716OtherCAQH