Provider Demographics
NPI:1952839409
Name:MAGNOLIA COUNSELING CENTER & SERVICES, LLC
Entity Type:Organization
Organization Name:MAGNOLIA COUNSELING CENTER & SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-382-3107
Mailing Address - Street 1:2130 GOVERNMENT ST STE A
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-3937
Mailing Address - Country:US
Mailing Address - Phone:228-382-3107
Mailing Address - Fax:800-854-0906
Practice Address - Street 1:2130 GOVERNMENT ST STE A
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-3937
Practice Address - Country:US
Practice Address - Phone:228-382-3107
Practice Address - Fax:800-854-0906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-29
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health