Provider Demographics
NPI:1730426198
Name:MAGNOLIA BEHAVIORAL HEALTH, INC.
Entity type:Organization
Organization Name:MAGNOLIA BEHAVIORAL HEALTH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MIRA
Authorized Official - Middle Name:MIRA
Authorized Official - Last Name:IHEME
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:770-724-8093
Mailing Address - Street 1:3350 NORTHLAKE PKWY NE
Mailing Address - Street 2:
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:
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?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-04
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health