Healthcare Provider Details

I. General information

NPI: 1003615238
Provider Name (Legal Business Name): SOUTHERN MAGNOLIA THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2025
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 N 173RD AVE APT 2
GOODYEAR AZ
85338-6712
US

IV. Provider business mailing address

25 N 173RD AVE APT 2
GOODYEAR AZ
85338-6712
US

V. Phone/Fax

Practice location:
  • Phone: 864-979-1325
  • Fax:
Mailing address:
  • Phone: 864-979-1325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. INGRAM MALCOLM KERRY DIRTON
Title or Position: CLINICAL DIRECTOR
Credential: LPC
Phone: 864-979-1325