Healthcare Provider Details

I. General information

NPI: 1154437739
Provider Name (Legal Business Name): WILLOW WELLNESS CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 02/12/2025
Certification Date: 02/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2604 DEMPSTER ST STE 401
PARK RIDGE IL
60068-8428
US

IV. Provider business mailing address

2604 DEMPSTER ST STE 402
PARK RIDGE IL
60068-8438
US

V. Phone/Fax

Practice location:
  • Phone: 847-318-8200
  • Fax: 224-478-0026
Mailing address:
  • Phone: 847-318-8200
  • Fax: 224-478-0026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. LISA CECILIA CAMPBELL
Title or Position: CO-DIRECTOR
Credential: PSY.D.
Phone: 847-318-8200