Provider Demographics
NPI:1790347896
Name:MAGNOLIA REHAB SERVICES
Entity Type:Organization
Organization Name:MAGNOLIA REHAB SERVICES
Other - Org Name:MAGNOLIA PEDIATRIC THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:C
Authorized Official - Last Name:NIX
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:850-226-8279
Mailing Address - Street 1:803 N WILSON ST
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-2639
Mailing Address - Country:US
Mailing Address - Phone:850-226-8279
Mailing Address - Fax:850-226-8326
Practice Address - Street 1:803 N WILSON ST
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-2639
Practice Address - Country:US
Practice Address - Phone:850-226-8279
Practice Address - Fax:850-226-8326
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAGNOLIA REHAB SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-06-28
Last Update Date:2022-09-29
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
FL002827600Medicaid