Provider Demographics
NPI:1740919711
Name:MAGNOLIA WELLNESS & PSYCHOLOGY, LLC
Entity type:Organization
Organization Name:MAGNOLIA WELLNESS & PSYCHOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TAMYRA
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:404-436-2368
Mailing Address - Street 1:306 EXCHANGE BLVD.
Mailing Address - Street 2:STE. 400, PMB 234
Mailing Address - City:BETHLEHEM
Mailing Address - State:GA
Mailing Address - Zip Code:30620
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:440 S PERRY ST STE 202
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4873
Practice Address - Country:US
Practice Address - Phone:404-436-2368
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-06
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty