Provider Demographics
NPI:1427281757
Name:MAGNOLIA PEDIATRIC THERAPY
Entity type:Organization
Organization Name:MAGNOLIA PEDIATRIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:GAUNT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-571-0033
Mailing Address - Street 1:340 W 23RD ST
Mailing Address - Street 2:SUITE H
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-7600
Mailing Address - Country:US
Mailing Address - Phone:850-215-3911
Mailing Address - Fax:850-215-3914
Practice Address - Street 1:340 W 23RD ST
Practice Address - Street 2:SUITE H
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-7600
Practice Address - Country:US
Practice Address - Phone:850-215-3911
Practice Address - Fax:850-215-3914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-03
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ4644252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency