Provider Demographics
NPI:1144944034
Name:WILLOW TREE THERAPY GROUP, LLC.
Entity type:Organization
Organization Name:WILLOW TREE THERAPY GROUP, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC-A
Authorized Official - Phone:843-560-4339
Mailing Address - Street 1:138 WATEREE DR
Mailing Address - Street 2:
Mailing Address - City:SANTEE
Mailing Address - State:SC
Mailing Address - Zip Code:29142-9309
Mailing Address - Country:US
Mailing Address - Phone:843-560-4339
Mailing Address - Fax:
Practice Address - Street 1:138 WATEREE DR
Practice Address - Street 2:
Practice Address - City:SANTEE
Practice Address - State:SC
Practice Address - Zip Code:29142-9309
Practice Address - Country:US
Practice Address - Phone:843-560-4339
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1255055141OtherINDIVIDUAL NPI