Provider Demographics
NPI:1003307414
Name:MAGNOLIA CLINICAL SERVICES
Entity Type:Organization
Organization Name:MAGNOLIA CLINICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:HUGHES
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:818-489-0866
Mailing Address - Street 1:5656 CANTALOUPE AVE
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-4712
Mailing Address - Country:US
Mailing Address - Phone:818-489-0846
Mailing Address - Fax:
Practice Address - Street 1:5656 CANTALOUPE AVE
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-4712
Practice Address - Country:US
Practice Address - Phone:818-489-0846
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-21
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty