Healthcare Provider Details

I. General information

NPI: 1114760071
Provider Name (Legal Business Name): MAGNOLIA DELGADO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5565 E ANAHEIM RD
LONG BEACH CA
90815-4329
US

IV. Provider business mailing address

1210 S WASHINGTON AVE
COMPTON CA
90221-4655
US

V. Phone/Fax

Practice location:
  • Phone: 562-453-9760
  • Fax:
Mailing address:
  • Phone: 424-278-5706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-24-73455
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: