Healthcare Provider Details

I. General information

NPI: 1053853515
Provider Name (Legal Business Name): MAGNOLIA COUNSELING AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2016
Last Update Date: 11/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 S MAIN ST STE 2G
JONESBORO GA
30236-3502
US

IV. Provider business mailing address

124 S MAIN ST STE 2G
JONESBORO GA
30236-3502
US

V. Phone/Fax

Practice location:
  • Phone: 470-629-3380
  • Fax:
Mailing address:
  • Phone: 470-629-3380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number009211
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN076947
License Number StateGA

VIII. Authorized Official

Name: MRS. FELITA DELORES BUSH
Title or Position: LPC
Credential: M.ED
Phone: 470-629-3380