Healthcare Provider Details

I. General information

NPI: 1205549896
Provider Name (Legal Business Name): WILLOW THERAPEUTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2022
Last Update Date: 12/29/2022
Certification Date: 12/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 GLENWOOD AVE
WILLOW SPRINGS IL
60480-1307
US

IV. Provider business mailing address

217 GLENWOOD AVE
WILLOW SPRINGS IL
60480-1307
US

V. Phone/Fax

Practice location:
  • Phone: 574-238-0438
  • Fax:
Mailing address:
  • Phone: 574-238-0438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE C GESSLER
Title or Position: MENTAL HEALTH COUNSELOR
Credential: LCPC
Phone: 574-238-0438