Active NPI
Robert W Wagner, LPC
- Mental Health Counselor
- Tyrone, GA
National Provider Identifier
1457309387
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Mental Health Counselor
- License
- 003153
- Practice address
- 105 Greencastle Rd
Suite B
Tyrone, GA 30290-2937 - Phone
- (770) 486-1011
- NPI assigned
- May 4, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Mental Health Counselor | 101YM0800X | 003153 | GA | Primary |
| Professional Counselor | 101YP2500X |
Addresses
Primary practice location
105 Greencastle Rd
Suite B
Tyrone, GA 30290-2937
Mailing address
105 Greencastle Rd
Suite B
Tyrone, GA 30290-2937
Phone (770) 757-7602
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in GA
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: No
- Power mobility devices: No
- Hospice: No
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20240129003330 | GA | Practitioner - Mental Health Counselor | 2062865702 | Practice locations: Peachtree City, GA |
Care Compare profile
Medicare Care Compare- Specialty
- Mental Health Counselor
- Education
- Other, 1996
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
Practice addresses (Care Compare)
111 Petrol PT
Suite C
Peachtree City, GA 30269-1553
Phone (770) 757-7602
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 003153 | GA | MD | Mental Health Counselor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1146700800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1198627200000",
"number": "1457309387",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "105 GREENCASTLE RD",
"address_2": "SUITE B",
"city": "TYRONE",
"state": "GA",
"postal_code": "302902937",
"telephone_number": "770-757-7602"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "105 GREENCASTLE RD",
"address_2": "SUITE B",
"city": "TYRONE",
"state": "GA",
"postal_code": "302902937",
"telephone_number": "770-486-1011"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WAGNER",
"first_name": "ROBERT",
"middle_name": "W",
"name_prefix": "Mr.",
"credential": "LPC",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-05-04",
"last_updated": "2007-12-26",
"status": "A"
},
"taxonomies": [
{
"code": "101YM0800X",
"taxonomy_group": "",
"desc": "Counselor, Mental Health",
"state": "GA",
"license": "003153",
"primary": true
},
{
"code": "101YP2500X",
"taxonomy_group": "",
"desc": "Counselor, Professional",
"state": null,
"license": null,
"primary": false
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Tyrone, GA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 26, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.