Provider Demographics
NPI:1073390589
Name:DESERT MAGNOLIA THERAPEUTIC SERVICES
Entity Type:Organization
Organization Name:DESERT MAGNOLIA THERAPEUTIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EVETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:MEI
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:602-284-4421
Mailing Address - Street 1:18217 W CAROL AVE
Mailing Address - Street 2:
Mailing Address - City:WADDELL
Mailing Address - State:AZ
Mailing Address - Zip Code:85355-4227
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18217 W CAROL AVE
Practice Address - Street 2:
Practice Address - City:WADDELL
Practice Address - State:AZ
Practice Address - Zip Code:85355-4227
Practice Address - Country:US
Practice Address - Phone:602-284-4421
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1518334366OtherNPI