Healthcare Provider Details

I. General information

NPI: 1245005222
Provider Name (Legal Business Name): MAGNOLIA THERAPY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2023
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1890 MCCULLOUGH BLVD STE 103
TUPELO MS
38801-6774
US

IV. Provider business mailing address

2622 EDGEMONT CIR
TUPELO MS
38804-1074
US

V. Phone/Fax

Practice location:
  • Phone: 662-322-0980
  • Fax:
Mailing address:
  • Phone: 662-322-0980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: ANDREA JONES
Title or Position: PT/OWNER
Credential: PT, DPT
Phone: 662-322-0980