Healthcare Provider Details

I. General information

NPI: 1518843853
Provider Name (Legal Business Name): WILLOW GLEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2025
Last Update Date: 08/13/2025
Certification Date: 08/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30800 CHAGRIN BLVD
CLEVELAND OH
44124-5925
US

IV. Provider business mailing address

30800 CHAGRIN BLVD
CLEVELAND OH
44124-5925
US

V. Phone/Fax

Practice location:
  • Phone: 216-329-1052
  • Fax:
Mailing address:
  • Phone: 216-329-1052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: ALICIA BLACKLEY
Title or Position: LPCC
Credential: LPCC
Phone: 216-329-1052