Provider Demographics
NPI:1164186730
Name:MAGNOLIA BEHAVIORAL AND HOLISTIC HEALTH
Entity Type:Organization
Organization Name:MAGNOLIA BEHAVIORAL AND HOLISTIC HEALTH
Other - Org Name:TINAMARIE FISH LMHC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TINAMARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FISH
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC, MHP, CCTP
Authorized Official - Phone:360-773-8964
Mailing Address - Street 1:PO BOX 826
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:WA
Mailing Address - Zip Code:98642-0826
Mailing Address - Country:US
Mailing Address - Phone:360-773-8964
Mailing Address - Fax:
Practice Address - Street 1:2512 E EVERGREEN BLVD # 1188
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-4323
Practice Address - Country:US
Practice Address - Phone:360-773-8964
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-28
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty