Healthcare Provider Details

I. General information

NPI: 1700424983
Provider Name (Legal Business Name): MAGNOLIA COUNSELING, LLC;
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2019
Last Update Date: 12/18/2019
Certification Date: 12/18/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1990 E LOHMAN AVE
LAS CRUCES NM
88001-3172
US

IV. Provider business mailing address

1990 E LOHMAN AVE
LAS CRUCES NM
88001-3172
US

V. Phone/Fax

Practice location:
  • Phone: 575-640-6760
  • Fax:
Mailing address:
  • Phone: 575-640-6760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MARISSA LOVE
Title or Position: PREISIDENT
Credential: LCPC
Phone: 575-640-6760