Provider Demographics
NPI:1508110800
Name:WIGGS, LOLITA D (MS, LPC)
Entity Type:Individual
Prefix:
First Name:LOLITA
Middle Name:D
Last Name:WIGGS
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3711 EXECUTIVE CENTER DRIVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-0952
Mailing Address - Country:US
Mailing Address - Phone:706-210-8855
Mailing Address - Fax:678-541-7699
Practice Address - Street 1:3711 EXECUTIVE CENTER DR
Practice Address - Street 2:SUITE 101
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-0951
Practice Address - Country:US
Practice Address - Phone:706-210-8855
Practice Address - Fax:678-541-7699
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-08
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008158101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003153686AMedicaid