Provider Demographics
NPI:1982217378
Name:AMY WAGNER, LLC
Entity Type:Organization
Organization Name:AMY WAGNER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:D
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MFT
Authorized Official - Phone:404-713-7313
Mailing Address - Street 1:346 KRAMER ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3708
Mailing Address - Country:US
Mailing Address - Phone:404-713-7313
Mailing Address - Fax:
Practice Address - Street 1:346 KRAMER ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3708
Practice Address - Country:US
Practice Address - Phone:404-713-7313
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-26
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty