Provider Demographics
NPI:1982969754
Name:WAGNER, KATHLEEN ANN (MA, LPC)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:ANN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 EMERALD LN
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-4234
Mailing Address - Country:US
Mailing Address - Phone:678-871-5927
Mailing Address - Fax:
Practice Address - Street 1:145 EMERALD LN
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4234
Practice Address - Country:US
Practice Address - Phone:678-871-5927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006769101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional