Healthcare Provider Details

I. General information

NPI: 1376407783
Provider Name (Legal Business Name): WILLOW PARK ACADEMY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/10/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 LAWN AVENUE UNIT D4
STAMFORD CT
06902
US

IV. Provider business mailing address

4 FARMWOODS LN
GLEN HEAD NY
11545-2730
US

V. Phone/Fax

Practice location:
  • Phone: 203-244-7438
  • Fax:
Mailing address:
  • Phone: 203-244-7438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: OWAIS IQBAL
Title or Position: PRESIDENT
Credential:
Phone: 516-474-8408