Provider Demographics
NPI:1134751753
Name:WILLOW TREE THERAPY SERVICES LLC
Entity type:Organization
Organization Name:WILLOW TREE THERAPY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:N
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:423-337-1635
Mailing Address - Street 1:19 W MACCLENNY AVE STE 111
Mailing Address - Street 2:
Mailing Address - City:MACCLENNY
Mailing Address - State:FL
Mailing Address - Zip Code:32063-2086
Mailing Address - Country:US
Mailing Address - Phone:904-349-5299
Mailing Address - Fax:
Practice Address - Street 1:19 W MACCLENNY AVE STE 111
Practice Address - Street 2:
Practice Address - City:MACCLENNY
Practice Address - State:FL
Practice Address - Zip Code:32063-2086
Practice Address - Country:US
Practice Address - Phone:904-349-5299
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-11
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty