Healthcare Provider Details

I. General information

NPI: 1154252203
Provider Name (Legal Business Name): WILLOW RESIDENTIAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2631 KENHILL DR
CHARLOTTE NC
28208-5912
US

IV. Provider business mailing address

2631 KENHILL DR
CHARLOTTE NC
28208-5912
US

V. Phone/Fax

Practice location:
  • Phone: 704-749-4564
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: AMANTII SAMSON
Title or Position: OWNER
Credential:
Phone: 704-749-4564