Provider Demographics
NPI:1306802301
Name:WAGES, M. DIANNE (LPC)
Entity type:Individual
Prefix:
First Name:M.
Middle Name:DIANNE
Last Name:WAGES
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 MEDICAL DR
Mailing Address - Street 2:M. DIANNE WAGES, LPC
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240
Mailing Address - Country:US
Mailing Address - Phone:706-885-0111
Mailing Address - Fax:706-885-0607
Practice Address - Street 1:300 MEDICAL DR
Practice Address - Street 2:M. DIANNE WAGES, LPC
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240
Practice Address - Country:US
Practice Address - Phone:706-885-0111
Practice Address - Fax:706-885-0607
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004106101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA337862151AMedicaid