Provider Demographics
NPI:1235457052
Name:MAGNOLIA REHAB SERVICES
Entity Type:Organization
Organization Name:MAGNOLIA REHAB SERVICES
Other - Org Name:MAGNOLIA PEDIATRIC THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:C
Authorized Official - Last Name:NIX
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:850-226-8279
Mailing Address - Street 1:1200 CROSSWINDS LNDG
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1174
Mailing Address - Country:US
Mailing Address - Phone:850-226-8279
Mailing Address - Fax:850-226-8326
Practice Address - Street 1:1200 CROSSWINDS LNDG
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1174
Practice Address - Country:US
Practice Address - Phone:850-226-8279
Practice Address - Fax:850-226-8326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-05
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 7938235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111422500Medicaid