Provider Demographics
NPI:1346690740
Name:MAGNOLIA PEDIATRIC THERAPY, LLC
Entity Type:Organization
Organization Name:MAGNOLIA PEDIATRIC THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:337-419-0086
Mailing Address - Street 1:3501 5TH AVE STE A
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70607-2155
Mailing Address - Country:US
Mailing Address - Phone:337-419-0086
Mailing Address - Fax:337-415-0626
Practice Address - Street 1:3501 5TH AVE STE A
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70607-2155
Practice Address - Country:US
Practice Address - Phone:337-419-0086
Practice Address - Fax:337-415-0626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-16
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7129235Z00000X
261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and SpeechGroup - Single Specialty