Provider Demographics
NPI:1093575722
Name:MAGNOLIA PSYCHIATRY LLC
Entity Type:Organization
Organization Name:MAGNOLIA PSYCHIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHILD AND ADOLESCENT PSYCHIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXIS ANGEL
Authorized Official - Middle Name:LAGTAPON
Authorized Official - Last Name:GUEVARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-256-3326
Mailing Address - Street 1:1001 ANNA KNAPP EXT
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-5412
Mailing Address - Country:US
Mailing Address - Phone:843-256-3326
Mailing Address - Fax:
Practice Address - Street 1:1001 ANNA KNAPP EXT
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-5412
Practice Address - Country:US
Practice Address - Phone:843-256-3326
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-20
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)