Provider Demographics
NPI:1487047049
Name:MAGNOLIA HEALTH CLINIC
Entity type:Organization
Organization Name:MAGNOLIA HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:IHEME
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LPC
Authorized Official - Phone:770-724-8093
Mailing Address - Street 1:3350 NORTHLAKE PKWY NE
Mailing Address - Street 2:SUITE B
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-2204
Mailing Address - Country:US
Mailing Address - Phone:770-724-8093
Mailing Address - Fax:
Practice Address - Street 1:3350 NORTHLAKE PKWY NE
Practice Address - Street 2:SUITE B
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-2204
Practice Address - Country:US
Practice Address - Phone:770-724-8093
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAGNOLIA BEHAVIORAL HEALTH, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-03-06
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA00222568261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care