Provider Demographics
NPI:1740986421
Name:MAGNOLIA WELLNESS CENTER
Entity type:Organization
Organization Name:MAGNOLIA WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:COLON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:773-294-7885
Mailing Address - Street 1:2724 W CHICAGO AVE APT 2F
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-5169
Mailing Address - Country:US
Mailing Address - Phone:773-294-7885
Mailing Address - Fax:
Practice Address - Street 1:36936 N CORONA DR
Practice Address - Street 2:
Practice Address - City:LAKE VILLA
Practice Address - State:IL
Practice Address - Zip Code:60046-5800
Practice Address - Country:US
Practice Address - Phone:773-294-7885
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-03
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty