Healthcare Provider Details

I. General information

NPI: 1376635102
Provider Name (Legal Business Name): WILLOWDALE COUNSELING CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 09/01/2021
Certification Date: 09/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 NORTHEASTERN BLVD STE 36A
NASHUA NH
03062-3196
US

IV. Provider business mailing address

76 NORTHEASTERN BLVD STE 36A
NASHUA NH
03062-3196
US

V. Phone/Fax

Practice location:
  • Phone: 603-881-7554
  • Fax: 603-881-7533
Mailing address:
  • Phone: 603-881-7554
  • Fax: 603-881-7533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number941
License Number StateNH

VIII. Authorized Official

Name: TIMOTHY C. BRAY
Title or Position: OWNER
Credential: PH.D.
Phone: 603-881-7554