Healthcare Provider Details

I. General information

NPI: 1396657367
Provider Name (Legal Business Name): WILLOW TELEPSYCHIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 N 2ND ST STE 100
RICHMOND KY
40475-1408
US

IV. Provider business mailing address

PO BOX 192
CROSS PLAINS TN
37049-0192
US

V. Phone/Fax

Practice location:
  • Phone: 859-379-9908
  • Fax: 859-461-8492
Mailing address:
  • Phone: 859-470-2540
  • Fax: 859-461-8492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: TINA MARIE EVANS
Title or Position: OWNER/SOLE MANAGER
Credential: PMHNP-BC
Phone: 859-470-2540