Healthcare Provider Details

I. General information

NPI: 1396036042
Provider Name (Legal Business Name): THE WILLOW TREE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2011
Last Update Date: 04/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 SPEEDWELL AVE
MORRIS PLAINS NJ
07950
US

IV. Provider business mailing address

415 SPEEDWELL AVE
MORRIS PLAINS NJ
07950
US

V. Phone/Fax

Practice location:
  • Phone: 973-682-8733
  • Fax: 973-682-8734
Mailing address:
  • Phone: 973-682-8733
  • Fax: 973-682-8734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number2000195-07
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37PC0822
License Number StateNJ

VIII. Authorized Official

Name: MR. CHARLES BERMAN
Title or Position: ASSOC DIRECTOR
Credential: LPC
Phone: 973-682-8733