=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750966362
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAGNOLIA SPRINGS COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2021
-----------------------------------------------------
Last Update Date | 03/15/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1726 KINGSLEY AVE STE 4
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32073-4411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-474-1477
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5000 US HIGHWAY 17 STE 18
-----------------------------------------------------
City | FLEMING ISLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32003-8250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-400-2345
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER / OWNER / LCSW
-----------------------------------------------------
Name | CAROLYN RENEE HUNTER
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 904-400-2345
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------