Provider Demographics
NPI:1912662396
Name:MAGNOLIA COUNSELING LLC
Entity Type:Organization
Organization Name:MAGNOLIA COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-235-3423
Mailing Address - Street 1:3817 RAYMOND AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2932
Mailing Address - Country:US
Mailing Address - Phone:314-623-4272
Mailing Address - Fax:
Practice Address - Street 1:3817 RAYMOND AVE
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2932
Practice Address - Country:US
Practice Address - Phone:314-623-4272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-01
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty