Healthcare Provider Details

I. General information

NPI: 1316858418
Provider Name (Legal Business Name): THE MAGNOLIA ABA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2873 HIGHWAY 49 S
FLORENCE MS
39073-9409
US

IV. Provider business mailing address

PO BOX 699
MAGEE MS
39111-0699
US

V. Phone/Fax

Practice location:
  • Phone: 601-613-2002
  • 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

VIII. Authorized Official

Name: MICHAEL BRADLEY
Title or Position: OWNER
Credential:
Phone: 601-613-2002