Provider Demographics
NPI:1558735050
Name:MAGNOLIA INSTRUCTIONAL CENTER
Entity Type:Organization
Organization Name:MAGNOLIA INSTRUCTIONAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MEGHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOUSEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-266-9620
Mailing Address - Street 1:2903 RR 620 N
Mailing Address - Street 2:BLDG B
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78734
Mailing Address - Country:US
Mailing Address - Phone:512-266-9620
Mailing Address - Fax:
Practice Address - Street 1:2903 RR 620 N
Practice Address - Street 2:BLDG B
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78734
Practice Address - Country:US
Practice Address - Phone:512-266-9620
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-20
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-13-13259103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty