Healthcare Provider Details

I. General information

NPI: 1780742874
Provider Name (Legal Business Name): WILLOWSTONE FAMILY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 05/03/2024
Certification Date: 05/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 N. 18TH ST. SUITE 101
LAFAYETTE IN
47904-3434
US

IV. Provider business mailing address

615 N. 18TH ST. SUITE 101
LAFAYETTE IN
47904-3434
US

V. Phone/Fax

Practice location:
  • Phone: 765-423-5361
  • Fax: 765-742-8272
Mailing address:
  • Phone: 765-423-5361
  • Fax: 765-742-8272

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: MRS. REBECCA SULLIVAN
Title or Position: CEO
Credential: LCSW
Phone: 765-423-5361