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General NPI Number Information
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NPI Number | 1558731604
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Entity Type | Organization
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Legal Business Name | MAGNOLIA INTEGRATED HEALTH, LLC
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Dates
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Enumeration Date | 10/01/2015
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Last Update Date | 10/01/2015
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Provider Practice Location Address
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Address Line | 2227 IDLEWOOD RD SUITE 2
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City | TUCKER
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State | GA
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Zip | 30084-4827
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Country | US
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Telephone | 678-922-2834
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Fax | 678-922-2270
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Provider Business Mailing Address
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Address Line | 2227 IDLEWOOD RD SUITE 2
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City | TUCKER
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State | GA
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Zip | 30084-4827
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Country | US
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Telephone | 678-922-2834
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Fax | 678-922-2270
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MIRA IHEME
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Credential | PH.D., LPC
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Telephone | 678-922-2834
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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 | LPC006908
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LPC005575
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LPC003902
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License Number State | GA
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Taxonomy #4
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | CSW005116
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License Number State | GA
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Taxonomy #5
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 69322
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License Number State | GA
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Taxonomy #6
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LPC002789
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License Number State | GA
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