Provider Demographics
NPI:1962104034
Name:THE MAGNOLIA GROUP CENTER FOR HEALTH AND WELLNESS
Entity type:Organization
Organization Name:THE MAGNOLIA GROUP CENTER FOR HEALTH AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:LAKESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROUSSARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-901-3458
Mailing Address - Street 1:8132 FOREST HILL AVE STE A
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23235-3265
Mailing Address - Country:US
Mailing Address - Phone:804-901-3458
Mailing Address - Fax:866-781-9646
Practice Address - Street 1:1233 MALL DR
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-4737
Practice Address - Country:US
Practice Address - Phone:804-625-9868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No251B00000XAgenciesCase Management