Healthcare Provider Details

I. General information

NPI: 1164186730
Provider Name (Legal Business Name): MAGNOLIA BEHAVIORAL AND HOLISTIC HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2021
Last Update Date: 06/16/2022
Certification Date: 06/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2512 E EVERGREEN BLVD # 1188
VANCOUVER WA
98661-4323
US

IV. Provider business mailing address

PO BOX 826
RIDGEFIELD WA
98642-0826
US

V. Phone/Fax

Practice location:
  • Phone: 360-773-8964
  • Fax:
Mailing address:
  • Phone: 360-773-8964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: TINAMARIE FISH
Title or Position: OWNER
Credential: LMHC, MHP, CCTP
Phone: 360-773-8964