Healthcare Provider Details

I. General information

NPI: 1023996147
Provider Name (Legal Business Name): MAGNOLIA BEHAVIOR HEALTH CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2025
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 SOLAREX CT UNIT 205
FREDERICK MD
21703-8655
US

IV. Provider business mailing address

604 SOLAREX CT UNIT 205
FREDERICK MD
21703-8655
US

V. Phone/Fax

Practice location:
  • Phone: 301-473-0954
  • Fax: 301-662-8063
Mailing address:
  • Phone: 301-304-0733
  • Fax: 301-662-8063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: JULIA SHIRIMA
Title or Position: CEO
Credential: RN
Phone: 301-305-5731