Healthcare Provider Details

I. General information

NPI: 1760174247
Provider Name (Legal Business Name): WILLOW ANXIETY AND OCD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2023
Last Update Date: 05/23/2023
Certification Date: 05/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 THE ALAMEDA SUITE 610/630
SAN JOSE CA
95126-1404
US

IV. Provider business mailing address

1900 THE ALAMEDA SUITE 610/630
SAN JOSE CA
95126-1404
US

V. Phone/Fax

Practice location:
  • Phone: 408-475-1665
  • Fax:
Mailing address:
  • Phone: 408-475-1665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: ALFREDO PEREZ
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 408-475-1665