Healthcare Provider Details

I. General information

NPI: 1508110800
Provider Name (Legal Business Name): LOLITA D WIGGS MS, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2012
Last Update Date: 12/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3711 EXECUTIVE CENTER DR SUITE 101
MARTINEZ GA
30907-0951
US

IV. Provider business mailing address

3711 EXECUTIVE CENTER DRIVE SUITE 101
MARTINEZ GA
30907-0952
US

V. Phone/Fax

Practice location:
  • Phone: 706-210-8855
  • Fax: 678-541-7699
Mailing address:
  • Phone: 706-210-8855
  • Fax: 678-541-7699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC008158
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: