Healthcare Provider Details

I. General information

NPI: 1407632037
Provider Name (Legal Business Name): MAGNOLIA FAMILY THERAPY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2023
Last Update Date: 09/08/2023
Certification Date: 09/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 MANAWAI ST APT 301
KAPOLEI HI
96707-4541
US

IV. Provider business mailing address

502 RICHEY PL
PEACHTREE CITY GA
30269-3644
US

V. Phone/Fax

Practice location:
  • Phone: 808-953-5049
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: LAUREN SERKIS
Title or Position: OWNER
Credential:
Phone: 808-953-5049