Healthcare Provider Details

I. General information

NPI: 1346152535
Provider Name (Legal Business Name): MAGNOLIA GROVE BEHAVIORAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3028 SOUTHERN ELM CT
FAIRFAX VA
22031-1101
US

IV. Provider business mailing address

3028 SOUTHERN ELM CT
FAIRFAX VA
22031-1101
US

V. Phone/Fax

Practice location:
  • Phone: 610-888-4484
  • Fax:
Mailing address:
  • Phone: 610-888-4484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: CHELSIA LAI WONG
Title or Position: BCBA
Credential:
Phone: 610-888-4484