Healthcare Provider Details

I. General information

NPI: 1124519764
Provider Name (Legal Business Name): WILLOW CLINICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2018
Last Update Date: 05/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 MANCHESTER RD STE 110
WHEATON IL
60187-2474
US

IV. Provider business mailing address

2150 MANCHESTER RD STE 110
WHEATON IL
60187-2474
US

V. Phone/Fax

Practice location:
  • Phone: 630-752-9874
  • Fax: 630-752-9875
Mailing address:
  • Phone: 708-955-1388
  • Fax: 630-752-9875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: CYNTHIA L REETZ
Title or Position: OWNER
Credential: MA, LCPC
Phone: 708-955-1388