Provider Demographics
NPI:1538612239
Name:WILLOW CREEK COUNSELING LLC
Entity type:Organization
Organization Name:WILLOW CREEK COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:CLAUDETTE
Authorized Official - Middle Name:M
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:651-356-2458
Mailing Address - Street 1:24050 40TH ST NE
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:MN
Mailing Address - Zip Code:56273-9699
Mailing Address - Country:US
Mailing Address - Phone:651-356-2458
Mailing Address - Fax:
Practice Address - Street 1:17 ASH STREET
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:MN
Practice Address - Zip Code:56273
Practice Address - Country:US
Practice Address - Phone:651-356-2458
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-28
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN167651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty