Healthcare Provider Details

I. General information

NPI: 1922620640
Provider Name (Legal Business Name): WILLOW RIDGE THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2020
Last Update Date: 05/15/2020
Certification Date: 05/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2532 WHEELER DR
CHELSEA MI
48118-9224
US

IV. Provider business mailing address

1163 S MAIN ST # 157
CHELSEA MI
48118-1408
US

V. Phone/Fax

Practice location:
  • Phone: 989-859-4472
  • Fax:
Mailing address:
  • Phone: 989-859-4472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. TAMARA STILES-BEECHEY
Title or Position: OWNER
Credential: LMSW
Phone: 989-859-4472