Healthcare Provider Details

I. General information

NPI: 1538943147
Provider Name (Legal Business Name): MAGNOLIA BEHAVIOR HEALTH CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2023
Last Update Date: 10/26/2023
Certification Date: 10/26/2023
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: 301-305-5731
  • Fax:
Mailing address:
  • Phone: 301-305-5731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. JULIA L SHIRIMA
Title or Position: CEO
Credential: NURSE
Phone: 301-305-5731