Provider Demographics
NPI:1467032953
Name:MAGNOLIA THERAPY LLC
Entity Type:Organization
Organization Name:MAGNOLIA THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:BROWN
Authorized Official - Last Name:CORBAN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:662-579-8508
Mailing Address - Street 1:206 SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38756-3139
Mailing Address - Country:US
Mailing Address - Phone:662-820-5044
Mailing Address - Fax:
Practice Address - Street 1:1502 S COLORADO ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-7219
Practice Address - Country:US
Practice Address - Phone:662-579-8508
Practice Address - Fax:601-586-8334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-09
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07509591Medicaid