Healthcare Provider Details

I. General information

NPI: 1578192936
Provider Name (Legal Business Name): MAGNOLIA HEALTH & WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 04/09/2020
Certification Date: 04/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 COMMERCE ST STE C
GREENVILLE NC
27858-5030
US

IV. Provider business mailing address

211 COMMERCE ST STE C
GREENVILLE NC
27858-5030
US

V. Phone/Fax

Practice location:
  • Phone: 252-320-9081
  • Fax:
Mailing address:
  • Phone: 252-320-9081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 10
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: WAQUIA MAULTSBY
Title or Position: OWNER/PRACTITIONER
Credential: FNP
Phone: 252-320-9081