Provider Demographics
NPI:1255090510
Name:MAGNOLIA PSYCHIATRY
Entity type:Organization
Organization Name:MAGNOLIA PSYCHIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SQUIRE
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:615-813-0726
Mailing Address - Street 1:4523 SHADY PLACE CT
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-4423
Mailing Address - Country:US
Mailing Address - Phone:937-285-0414
Mailing Address - Fax:
Practice Address - Street 1:312 S 4TH ST STE 700
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3046
Practice Address - Country:US
Practice Address - Phone:615-813-0726
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-14
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty