Provider Demographics
NPI:1033578018
Name:MAGNOLIA BEHAVIORAL PSYCHOLOGY, PLLC
Entity Type:Organization
Organization Name:MAGNOLIA BEHAVIORAL PSYCHOLOGY, PLLC
Other - Org Name:MAGNOLIA BEHAVIORAL PSYCHOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:DART
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LP
Authorized Official - Phone:985-373-1497
Mailing Address - Street 1:6668 HWY 98
Mailing Address - Street 2:SUITE A
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-9098
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6668 HWY 98
Practice Address - Street 2:SUITE A
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-9098
Practice Address - Country:US
Practice Address - Phone:601-348-7792
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-18
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS55978103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty