MEDICARE: WILLOW COLLECTIVE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker
2	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1033874995
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLOW COLLECTIVE

Provider Business Mailing Address
First Line	:	375 E HORSETOOTH RD BLDG 6201
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-6800
Country	:	US
Telephone Number	:	970-581-5155
Fax Number	:

Provider Business Practice Location Address
First Line	:	375 E HORSETOOTH RD BLDG 6201
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-6800
Country	:	US
Telephone Number	:	970-581-5155
Fax Number	:

Authorized Official
Title or Position	:	MANAGER/MEMBER
Name	:	MARY ELIZABETH SWANSON
Credential	:	LCSW
Telephone Number	:	970-581-5155

Provider Enumeration Date	:	11/05/2021
Last Update Date	:	09/09/2022

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