Provider Demographics
NPI:1700424983
Name:MAGNOLIA COUNSELING, LLC;
Entity Type:Organization
Organization Name:MAGNOLIA COUNSELING, LLC;
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PREISIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOVE
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:575-640-6760
Mailing Address - Street 1:1990 E LOHMAN AVE
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-3172
Mailing Address - Country:US
Mailing Address - Phone:575-640-6760
Mailing Address - Fax:
Practice Address - Street 1:1990 E LOHMAN AVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-3172
Practice Address - Country:US
Practice Address - Phone:575-640-6760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-18
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM31752039Medicaid