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General NPI Number Information
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NPI Number | 1033578018
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Entity Type | Organization
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Legal Business Name | MAGNOLIA BEHAVIORAL PSYCHOLOGY, PLLC
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Dates
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Enumeration Date | 02/18/2016
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Last Update Date | 09/29/2016
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Provider Practice Location Address
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Address Line | 6668 HWY 98 SUITE A
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City | HATTIESBURG
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State | MS
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Zip | 39402-9098
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Country | US
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Telephone | 601-348-7792
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Fax |
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Provider Business Mailing Address
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Address Line | 6668 HWY 98 SUITE A
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City | HATTIESBURG
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State | MS
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Zip | 39402-9098
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | LICENSED PSYCHOLOGIST
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Name | DR. EVAN HENRY DART
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Credential | PH.D., LP
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Telephone | 985-373-1497
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 55978
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License Number State | MS
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