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General NPI Number Information
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NPI Number | 1083420103
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Entity Type | Organization
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Legal Business Name | MAGNOLIA MINDFULNESS LLC
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Dates
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Enumeration Date | 12/04/2024
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Last Update Date | 12/04/2024
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Provider Practice Location Address
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Address Line | 3109 S GRAND BLVD STE 260H
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City | SAINT LOUIS
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State | MO
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Zip | 63118-1090
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Country | US
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Telephone | 314-608-7305
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Fax |
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Provider Business Mailing Address
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Address Line | 3542 SIDNEY ST
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City | SAINT LOUIS
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State | MO
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Zip | 63104-1778
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Country | US
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Telephone | 314-608-7305
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ALEXIS SHORT
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Credential | LCSW
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Telephone | 314-608-7305
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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