Provider Demographics
NPI:1053749168
Name:WAGNER, MATTHEW (LPC, CAADC)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:LPC, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 N MCDONOUGH ST STE 212
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-3310
Mailing Address - Country:US
Mailing Address - Phone:770-766-8128
Mailing Address - Fax:
Practice Address - Street 1:545 N MCDONOUGH ST STE 212
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-3310
Practice Address - Country:US
Practice Address - Phone:770-766-8128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-29
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAC0212101YA0400X
GA9583101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)