Healthcare Provider Details

I. General information

NPI: 1346690740
Provider Name (Legal Business Name): MAGNOLIA PEDIATRIC THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2016
Last Update Date: 03/22/2023
Certification Date: 03/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 5TH AVE STE A
LAKE CHARLES LA
70607-2155
US

IV. Provider business mailing address

3501 5TH AVE STE A
LAKE CHARLES LA
70607-2155
US

V. Phone/Fax

Practice location:
  • Phone: 337-419-0086
  • Fax: 337-415-0626
Mailing address:
  • Phone: 337-419-0086
  • Fax: 337-415-0626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7129
License Number StateLA

VIII. Authorized Official

Name: MEGAN MUSSO
Title or Position: MANAGER/OWNER
Credential: M.A., CCC-SLP
Phone: 337-419-0086