Provider Demographics
NPI:1952940454
Name:MAGNOLIA COUNSELING CLINIC
Entity Type:Organization
Organization Name:MAGNOLIA COUNSELING CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CODY
Authorized Official - Middle Name:WILLIAMS
Authorized Official - Last Name:GOSS
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:662-563-8703
Mailing Address - Street 1:590 HIGHWAY 6 E
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38606-3002
Mailing Address - Country:US
Mailing Address - Phone:662-563-8703
Mailing Address - Fax:
Practice Address - Street 1:590 HIGHWAY 6 E
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:MS
Practice Address - Zip Code:38606-3002
Practice Address - Country:US
Practice Address - Phone:662-563-8703
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-31
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Multi-Specialty