Healthcare Provider Details

I. General information

NPI: 1134940174
Provider Name (Legal Business Name): MAGNOLIA MENTAL HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2024
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 E 2ND NORTH ST
SUMMERVILLE SC
29483-2157
US

IV. Provider business mailing address

318 POND HILL CT
SUMMERVILLE SC
29483-5417
US

V. Phone/Fax

Practice location:
  • Phone: 843-934-4007
  • Fax:
Mailing address:
  • Phone: 509-828-8898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: CHRISTINE REISDORPH
Title or Position: OWNER
Credential: APRN
Phone: 843-934-4007