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General NPI Number Information
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NPI Number | 1760981740
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Entity Type | Organization
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Legal Business Name | MAGNOLIA PSYCHOLOGICAL ASSOCIATES, INC.
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Dates
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Enumeration Date | 02/06/2018
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Last Update Date | 12/15/2022
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Provider Practice Location Address
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Address Line | 2530 CRAWFORD AVE STE 203
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City | EVANSTON
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State | IL
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Zip | 60201-4959
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Country | US
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Telephone | 630-534-3122
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 402
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City | SKOKIE
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State | IL
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Zip | 60076-0402
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Country | US
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Telephone | 630-534-3122
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Fax |
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Authorized Official
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Title or Position | CLINICAL PSYCHOLOGIST
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Name | ERIKA KNUTH
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Credential | PHD
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Telephone | 630-534-3122
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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