Healthcare Provider Details

I. General information

NPI: 1114455615
Provider Name (Legal Business Name): MAGNOLIA FAMILY COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2017
Last Update Date: 12/02/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 HIGHWAY 123 STE C
SENECA SC
29678-0855
US

IV. Provider business mailing address

259 WINSTEAD RD
WEST UNION SC
29696-3026
US

V. Phone/Fax

Practice location:
  • Phone: 864-710-4723
  • Fax: 864-752-1186
Mailing address:
  • Phone: 864-710-4723
  • Fax: 864-752-1186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3474
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DEBRA CULBERTSON
Title or Position: OWNER
Credential: MED, LPC, LAC, LPCS
Phone: 864-710-4723