Healthcare Provider Details

I. General information

NPI: 1689176323
Provider Name (Legal Business Name): MAGNOLIA PEDIATRIC THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2018
Last Update Date: 03/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

239 CLARK FARMS RD
MADISON MS
39110-8115
US

IV. Provider business mailing address

239 CLARK FARMS RD
MADISON MS
39110-8115
US

V. Phone/Fax

Practice location:
  • Phone: 601-519-8930
  • Fax:
Mailing address:
  • Phone: 601-519-8930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT1767
License Number StateMS

VIII. Authorized Official

Name: JAMIE AUSTIN
Title or Position: OCCUPATIONAL THERAPIST
Credential: OTR/L
Phone: 601-519-8930