Healthcare Provider Details

I. General information

NPI: 1245069616
Provider Name (Legal Business Name): WILLOW TREE LICENSED CLINICAL SOCIAL WORKER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2024
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2103 S EL CAMINO REAL STE 202
OCEANSIDE CA
92054-6281
US

IV. Provider business mailing address

2103 S EL CAMINO REAL STE 202
OCEANSIDE CA
92054-6281
US

V. Phone/Fax

Practice location:
  • Phone: 442-500-8548
  • Fax: 760-400-8379
Mailing address:
  • Phone: 442-500-8548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: DR. SIBELIA LISANNE CHAIYAHAT
Title or Position: CEO
Credential: LCSW
Phone: 442-500-8548