Healthcare Provider Details

I. General information

NPI: 1053914788
Provider Name (Legal Business Name): WILLOW TREE COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2020
Last Update Date: 04/20/2023
Certification Date: 04/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1612 BONFORTE BLVD
PUEBLO CO
81001-1603
US

IV. Provider business mailing address

1612 BONFORTE BLVD
PUEBLO CO
81001-1603
US

V. Phone/Fax

Practice location:
  • Phone: 719-696-8426
  • Fax: 719-696-9432
Mailing address:
  • Phone: 719-696-8426
  • Fax: 719-696-9432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLEE BALAGAT
Title or Position: OWNER
Credential: LCSW
Phone: 719-696-8426