Provider Demographics
NPI:1851035646
Name:MAGNOLIA WELLNESS, LLC
Entity Type:Organization
Organization Name:MAGNOLIA WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:JOLI
Authorized Official - Last Name:DURNELL-GRADY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:484-254-4015
Mailing Address - Street 1:238 BARCLAY RD
Mailing Address - Street 2:
Mailing Address - City:UPPER DARBY
Mailing Address - State:PA
Mailing Address - Zip Code:19082-1202
Mailing Address - Country:US
Mailing Address - Phone:484-254-4015
Mailing Address - Fax:
Practice Address - Street 1:238 BARCLAY RD
Practice Address - Street 2:
Practice Address - City:UPPER DARBY
Practice Address - State:PA
Practice Address - Zip Code:19082-1202
Practice Address - Country:US
Practice Address - Phone:484-254-4015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-26
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty