Provider Demographics
NPI:1629402094
Name:KATHY WAGNER COUNSELING SERVICES LLC
Entity type:Organization
Organization Name:KATHY WAGNER COUNSELING SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:678-871-5927
Mailing Address - Street 1:175 MANOR DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-2959
Mailing Address - Country:US
Mailing Address - Phone:678-871-5927
Mailing Address - Fax:770-995-1959
Practice Address - Street 1:262 S PEACHTREE PKWY
Practice Address - Street 2:STE 4
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-1751
Practice Address - Country:US
Practice Address - Phone:678-871-5927
Practice Address - Fax:770-995-1959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-21
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006769101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty