Provider Demographics
NPI:1306031752
Name:MAGNOLIA PSYCHIATRIC PA
Entity Type:Organization
Organization Name:MAGNOLIA PSYCHIATRIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MATTINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-818-0563
Mailing Address - Street 1:2124 GOVERNMENT ST
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-3937
Mailing Address - Country:US
Mailing Address - Phone:228-818-9050
Mailing Address - Fax:228-872-6300
Practice Address - Street 1:2124 GOVERNMENT ST
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-3937
Practice Address - Country:US
Practice Address - Phone:228-818-9050
Practice Address - Fax:228-872-6300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18977103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSI45088Medicare UPIN