Healthcare Provider Details

I. General information

NPI: 1730015413
Provider Name (Legal Business Name): WILLOW WELLNESS COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 DURBIN STATION CT STE 303
ST JOHNS FL
32259-9368
US

IV. Provider business mailing address

1075 OAKLEAF PLANTATION PKWY STE 304-143
ORANGE PARK FL
32065-3624
US

V. Phone/Fax

Practice location:
  • Phone: 904-274-0065
  • Fax:
Mailing address:
  • Phone: 904-274-0065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: TIFFANY CUMMINS
Title or Position: OWNER
Credential: LMHC
Phone: 904-274-0065