Healthcare Provider Details

I. General information

NPI: 1952940454
Provider Name (Legal Business Name): MAGNOLIA COUNSELING CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2019
Last Update Date: 01/13/2020
Certification Date: 01/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 HIGHWAY 6 E
BATESVILLE MS
38606-3002
US

IV. Provider business mailing address

590 HIGHWAY 6 E
BATESVILLE MS
38606-3002
US

V. Phone/Fax

Practice location:
  • Phone: 662-563-8703
  • Fax:
Mailing address:
  • Phone: 662-563-8703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: CODY WILLIAMS GOSS
Title or Position: OFFICE MANAGER
Credential: LPN
Phone: 662-563-8703