MEDICARE: KATHY WAGNER COUNSELING SERVICES LLC

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	101YP2500X	Professional Counselor	LPC006769	GA

General Provider Information

NPI Number	:	1629402094
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KATHY WAGNER COUNSELING SERVICES LLC

Provider Business Mailing Address
First Line	:	175 MANOR DR
Second Line	:
City	:	FAYETTEVILLE
State	:	GA
Zip	:	30215-2959
Country	:	US
Telephone Number	:	678-871-5927
Fax Number	:	770-995-1959

Provider Business Practice Location Address
First Line	:	262 S PEACHTREE PKWY
Second Line	:	STE 4
City	:	PEACHTREE CITY
State	:	GA
Zip	:	30269-1751
Country	:	US
Telephone Number	:	678-871-5927
Fax Number	:	770-995-1959

Authorized Official
Title or Position	:	OWNER
Name	:	KATHLEEN A WAGNER
Credential	:	LPC
Telephone Number	:	678-871-5927

Provider Enumeration Date	:	08/21/2013
Last Update Date	:	08/21/2013

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