Provider Demographics
NPI:1053853515
Name:MAGNOLIA COUNSELING AND WELLNESS
Entity Type:Organization
Organization Name:MAGNOLIA COUNSELING AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPC
Authorized Official - Prefix:MRS
Authorized Official - First Name:FELITA
Authorized Official - Middle Name:DELORES
Authorized Official - Last Name:BUSH
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:470-629-3380
Mailing Address - Street 1:124 S MAIN ST STE 2G
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-3502
Mailing Address - Country:US
Mailing Address - Phone:470-629-3380
Mailing Address - Fax:
Practice Address - Street 1:124 S MAIN ST STE 2G
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-3502
Practice Address - Country:US
Practice Address - Phone:470-629-3380
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-14
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA009211101YP2500X
GARN076947163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty