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General NPI Number Information
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NPI Number | 1053853515
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Entity Type | Organization
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Legal Business Name | MAGNOLIA COUNSELING AND WELLNESS
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Dates
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Enumeration Date | 11/14/2016
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Last Update Date | 11/14/2016
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Provider Practice Location Address
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Address Line | 124 S MAIN ST STE 2G
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City | JONESBORO
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State | GA
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Zip | 30236-3502
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Country | US
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Telephone | 470-629-3380
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Fax |
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Provider Business Mailing Address
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Address Line | 124 S MAIN ST STE 2G
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City | JONESBORO
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State | GA
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Zip | 30236-3502
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Country | US
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Telephone | 470-629-3380
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Fax |
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Authorized Official
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Title or Position | LPC
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Name | MRS. FELITA DELORES BUSH
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Credential | M.ED
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Telephone | 470-629-3380
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 009211
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | RN076947
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License Number State | GA
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