Healthcare Provider Details

I. General information

NPI: 1508760042
Provider Name (Legal Business Name): MAGNOLIA PINES COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 ENGRAM ST
MONTEZUMA GA
31063-1518
US

IV. Provider business mailing address

404 ENGRAM ST
MONTEZUMA GA
31063-1518
US

V. Phone/Fax

Practice location:
  • Phone: 801-628-3092
  • Fax:
Mailing address:
  • Phone: 801-628-3092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KARSON KINIKINI
Title or Position: CMHC
Credential: CMHC
Phone: 801-628-3092