Healthcare Provider Details

I. General information

NPI: 1811753874
Provider Name (Legal Business Name): MAGNOLIA AUTISM GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2024
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 GUILFORD AVE # 1555
BALTIMORE MD
21202-3707
US

IV. Provider business mailing address

440 N BARRANCA AVE # 9605
COVINA CA
91723-1722
US

V. Phone/Fax

Practice location:
  • Phone: 510-457-1492
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: QINGQING MAO
Title or Position: CTO
Credential:
Phone: 415-805-1725