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General NPI Number Information
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NPI Number | 1396445037
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Entity Type | Organization
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Legal Business Name | MAGNOLIA BEHAVIORAL THERAPY, LLC
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Dates
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Enumeration Date | 03/09/2023
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Last Update Date | 03/09/2023
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Provider Practice Location Address
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Address Line | 3501 5TH AVE STE C1
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City | LAKE CHARLES
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State | LA
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Zip | 70607-2155
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Country | US
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Telephone | 337-419-0086
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Fax |
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Provider Business Mailing Address
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Address Line | 1100 HENRIETTA LN
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City | LAKE CHARLES
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State | LA
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Zip | 70605-1415
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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 | MANAGER
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Name | MEGAN MUSSO
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Credential |
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Telephone | 337-912-9006
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number |
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License Number State |
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