Provider Demographics
NPI:1275317935
Name:MAGNOLIA BEHAVIOR HEALTH CENTER LLC
Entity Type:Organization
Organization Name:MAGNOLIA BEHAVIOR HEALTH CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIRIMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-919-6062
Mailing Address - Street 1:604 SOLAREX CT UNIT 205
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21703-8655
Mailing Address - Country:US
Mailing Address - Phone:240-919-6062
Mailing Address - Fax:301-698-8789
Practice Address - Street 1:604 SOLAREX CT UNIT 205
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703-8655
Practice Address - Country:US
Practice Address - Phone:240-919-6062
Practice Address - Fax:301-698-8789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-23
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency