Provider Demographics
NPI:1003615238
Name:SOUTHERN MAGNOLIA THERAPY LLC
Entity type:Organization
Organization Name:SOUTHERN MAGNOLIA THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:INGRAM
Authorized Official - Middle Name:MALCOLM KERRY
Authorized Official - Last Name:DIRTON
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:864-979-1325
Mailing Address - Street 1:708 S LINDON LN
Mailing Address - Street 2:APT 5020A
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85281
Mailing Address - Country:US
Mailing Address - Phone:864-979-1325
Mailing Address - Fax:
Practice Address - Street 1:708 S LINDON LN
Practice Address - Street 2:APT 5020A
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281
Practice Address - Country:US
Practice Address - Phone:864-979-1325
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-11
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty