Basic Information
| Provider Information | |||||||||
| NPI: | 1295851640 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORRIS | ||||||||
| FirstName: | MAGNOLIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MAGGETT | ||||||||
| OtherFirstName: | MAGNOLIA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 644 SEMINOLE | ||||||||
| Address2: | |||||||||
| City: | WEST HELENA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723901512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705723136 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1825 E BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | FORREST CITY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723353409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8706302328 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.