Provider Demographics
NPI:1528678752
Name:MAGNOLIA CENTER, PLLC
Entity type:Organization
Organization Name:MAGNOLIA CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PSYCHOLOGIST
Authorized Official - Prefix:MS
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:THORNTON
Authorized Official - Suffix:
Authorized Official - Credentials:LPA
Authorized Official - Phone:336-407-9548
Mailing Address - Street 1:1400 OLD MILL CIR STE B
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-2977
Mailing Address - Country:US
Mailing Address - Phone:336-407-9548
Mailing Address - Fax:336-995-2579
Practice Address - Street 1:1400 OLD MILL CIR STE B
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2977
Practice Address - Country:US
Practice Address - Phone:336-407-9548
Practice Address - Fax:336-995-2579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-03
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)