1003615238 NPI number — SOUTHERN MAGNOLIA THERAPY LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003615238 NPI number — SOUTHERN MAGNOLIA THERAPY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN MAGNOLIA THERAPY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003615238
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/11/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
708 S LINDON LN
Provider Second Line Business Mailing Address:
APT 5020A
Provider Business Mailing Address City Name:
TEMPE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85281
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-979-1325
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
708 S LINDON LN
Provider Second Line Business Practice Location Address:
APT 5020A
Provider Business Practice Location Address City Name:
TEMPE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85281
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-979-1325
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/11/2025

Additional Information

Authorized Official

Authorized Official Last Name:
DIRTON
Authorized Official First Name:
INGRAM
Authorized Official Middle Name:
MALCOLM KERRY
Authorized Official Title or Position:
CLINICAL DIRECTOR
Authorized Official Telephone Number:
864-979-1325

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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