Healthcare Provider Details

I. General information

NPI: 1386572873
Provider Name (Legal Business Name): WILLOW WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5908 E CHALMERS RD
MONTICELLO IN
47960-7663
US

IV. Provider business mailing address

5908 E CHALMERS RD
MONTICELLO IN
47960-7663
US

V. Phone/Fax

Practice location:
  • Phone: 785-338-6986
  • Fax: 785-338-6986
Mailing address:
  • Phone: 785-338-6986
  • Fax: 785-338-6986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: SHANA K FUNK
Title or Position: MANAGER
Credential: LCSW
Phone: 785-338-6986