Provider Demographics
NPI:1083502249
Name:MAGNOLIA ROOTS COLLECTIVE AND COUNSELING PLLC
Entity type:Organization
Organization Name:MAGNOLIA ROOTS COLLECTIVE AND COUNSELING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:704-253-0450
Mailing Address - Street 1:405 47TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50265-7100
Mailing Address - Country:US
Mailing Address - Phone:704-253-0450
Mailing Address - Fax:
Practice Address - Street 1:405 47TH ST
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50265-7100
Practice Address - Country:US
Practice Address - Phone:704-253-0450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-26
Last Update Date:2025-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1861189508Medicaid