MEDICARE: MAGNOLIA BEHAVIORAL HEALTH, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0855X	Adolescent and Children Mental Health Clinic/Center		GA

General Provider Information

NPI Number	:	1730426198
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGNOLIA BEHAVIORAL HEALTH, INC.

Provider Business Mailing Address
First Line	:	3350 NORTHLAKE PKWY NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30345-2204
Country	:	US
Telephone Number	:	770-724-8093
Fax Number	:

Provider Business Practice Location Address
First Line	:	3350 NORTHLAKE PKWY NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30345-2204
Country	:	US
Telephone Number	:	770-724-8093
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MIRA MIRA IHEME
Credential	:	PH.D.
Telephone Number	:	770-724-8093

Provider Enumeration Date	:	01/04/2013
Last Update Date	:	01/04/2013

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