Provider Demographics
NPI:1588010193
Name:MAGNOLIA FAMILY SUPPORT & INTERVENTIONS, LLC
Entity type:Organization
Organization Name:MAGNOLIA FAMILY SUPPORT & INTERVENTIONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHATORYA
Authorized Official - Middle Name:
Authorized Official - Last Name:NASH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-675-1112
Mailing Address - Street 1:809 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-2113
Mailing Address - Country:US
Mailing Address - Phone:318-675-1112
Mailing Address - Fax:866-307-9980
Practice Address - Street 1:809 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-2113
Practice Address - Country:US
Practice Address - Phone:318-675-1112
Practice Address - Fax:866-307-9980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-12
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health