Provider Demographics
NPI:1922435593
Name:MAGNOLIA COUNSELING LLC
Entity Type:Organization
Organization Name:MAGNOLIA COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED MARITAL & FAMILY THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:860-668-1444
Mailing Address - Street 1:11 HIGH ST STE 202
Mailing Address - Street 2:
Mailing Address - City:SUFFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06078-2125
Mailing Address - Country:US
Mailing Address - Phone:860-668-1444
Mailing Address - Fax:860-668-1446
Practice Address - Street 1:11 HIGH ST STE 202
Practice Address - Street 2:
Practice Address - City:SUFFIELD
Practice Address - State:CT
Practice Address - Zip Code:06078-2125
Practice Address - Country:US
Practice Address - Phone:860-668-1444
Practice Address - Fax:860-668-1446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-27
Last Update Date:2023-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000724106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008038165Medicaid