Provider Demographics
NPI:1205582665
Name:WILLOW TREE PAIN AND ADDICTION CLINIC, PLLC
Entity type:Organization
Organization Name:WILLOW TREE PAIN AND ADDICTION CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACNP/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CORA
Authorized Official - Middle Name:PAULETTE
Authorized Official - Last Name:KEARLEY
Authorized Official - Suffix:
Authorized Official - Credentials:ACNP
Authorized Official - Phone:252-864-3852
Mailing Address - Street 1:703 ROSANNE DR # D
Mailing Address - Street 2:
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28504-1551
Mailing Address - Country:US
Mailing Address - Phone:252-643-2630
Mailing Address - Fax:252-643-2628
Practice Address - Street 1:703 ROSANNE DR # D
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28504-1551
Practice Address - Country:US
Practice Address - Phone:252-643-2630
Practice Address - Fax:252-643-2628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-24
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain