Provider Demographics
NPI:1033583372
Name:MAGNOLIA BEHAVIOR THERAPY
Entity Type:Organization
Organization Name:MAGNOLIA BEHAVIOR THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTATOR
Authorized Official - Prefix:
Authorized Official - First Name:MCCULLOUGH
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-453-4882
Mailing Address - Street 1:3214 W MCGRAW ST
Mailing Address - Street 2:SUITE 212
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98199-3239
Mailing Address - Country:US
Mailing Address - Phone:206-453-4882
Mailing Address - Fax:
Practice Address - Street 1:3214 W MCGRAW ST
Practice Address - Street 2:SUITE 212
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98199-3239
Practice Address - Country:US
Practice Address - Phone:206-453-4882
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-24
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60618517103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty