Healthcare Provider Details

I. General information

NPI: 1629670922
Provider Name (Legal Business Name): MAGNOLIA WELLNESS SOLUTIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2020
Last Update Date: 11/11/2020
Certification Date: 11/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

823 VILLA RIDGE PKWY
LAWRENCEVILLE GA
30044-2314
US

IV. Provider business mailing address

823 VILLA RIDGE PKWY
LAWRENCEVILLE GA
30044-2314
US

V. Phone/Fax

Practice location:
  • Phone: 773-412-0694
  • Fax:
Mailing address:
  • Phone: 773-412-0694
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. TAMYRA CROSSLEY
Title or Position: CLINICAL DIRECTOR
Credential: PSY.D.
Phone: 678-679-6155