Healthcare Provider Details

I. General information

NPI: 1891420733
Provider Name (Legal Business Name): WILLOW TREE COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2022
Last Update Date: 10/30/2023
Certification Date: 08/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 N MAIN ST
ROCKY FORD CO
81067-1256
US

IV. Provider business mailing address

2227 N ELIZABETH ST
PUEBLO CO
81003-1809
US

V. Phone/Fax

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

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: KIMBERLY BALAGAT
Title or Position: OWNER
Credential: CLSW
Phone: 719-528-0959