MEDICARE: LAURA BETH WAGAR LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	LPC009134	GA
2	101YP2500X	Professional Counselor	LPC009134	GA

General Provider Information

NPI Number	:	1376161224
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA BETH WAGAR LPC

Provider Business Mailing Address
First Line	:	903 SUBLIME TRL
Second Line	:
City	:	CANTON
State	:	GA
Zip	:	30114-7280
Country	:	US
Telephone Number	:	404-626-5500
Fax Number	:

Provider Business Practice Location Address
First Line	:	203 OAKSIDE LN STE F
Second Line	:
City	:	CANTON
State	:	GA
Zip	:	30114-6407
Country	:	US
Telephone Number	:	678-213-2194
Fax Number	:	404-806-1832

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2020
Last Update Date	:	02/05/2025

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