Provider Demographics
NPI:1083387393
Name:MAGNOLIA THERAPY AND WELLNESS
Entity Type:Organization
Organization Name:MAGNOLIA THERAPY AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CHITTENDEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:616-446-2265
Mailing Address - Street 1:269 WALKER ST STE 122
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-4258
Mailing Address - Country:US
Mailing Address - Phone:616-446-2265
Mailing Address - Fax:
Practice Address - Street 1:1731 VAN DYKE ST APT 1
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48214-2633
Practice Address - Country:US
Practice Address - Phone:616-446-2265
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-01
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)