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General NPI Number Information
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NPI Number | 1962104034
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Entity Type | Organization
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Legal Business Name | THE MAGNOLIA GROUP CENTER FOR HEALTH AND WELLNESS
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Dates
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Enumeration Date | 03/21/2023
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Last Update Date | 03/21/2023
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Provider Practice Location Address
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Address Line | 1233 MALL DR
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City | NORTH CHESTERFIELD
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State | VA
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Zip | 23235-4737
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Country | US
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Telephone | 804-625-9868
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Fax |
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Provider Business Mailing Address
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Address Line | 8132 FOREST HILL AVE STE A
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City | NORTH CHESTERFIELD
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State | VA
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Zip | 23235-3265
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Country | US
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Telephone | 804-901-3458
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Fax | 866-781-9646
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Authorized Official
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Title or Position | DIRECTOR OF SERVICES
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Name | LAKESHA BROUSSARD
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Credential |
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Telephone | 804-901-3458
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #3
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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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Taxonomy #4
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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