Provider Demographics
NPI:1720423023
Name:MAGNOLIA'S HEART INCORPORATED LLC
Entity Type:Organization
Organization Name:MAGNOLIA'S HEART INCORPORATED LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOFFETT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:702-201-1657
Mailing Address - Street 1:PO BOX 46212
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-6212
Mailing Address - Country:US
Mailing Address - Phone:702-201-1657
Mailing Address - Fax:702-921-3333
Practice Address - Street 1:4550 W OAKEY BLVD STE 111M
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1581
Practice Address - Country:US
Practice Address - Phone:702-201-1657
Practice Address - Fax:702-921-3333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-01
Last Update Date:2020-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty