Healthcare Provider Details

I. General information

NPI: 1295517670
Provider Name (Legal Business Name): WILLOW THERAPY AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2023
Last Update Date: 10/09/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 COMMERCE DR
FORT WASHINGTON PA
19034-2600
US

IV. Provider business mailing address

1713 STARR LN
GLENSIDE PA
19038-1400
US

V. Phone/Fax

Practice location:
  • Phone: 484-416-0583
  • Fax:
Mailing address:
  • Phone: 443-480-3673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL

VIII. Authorized Official

Name: ELYSE WILLIAMS
Title or Position: OWNER/CLINICIAN
Credential: LPC
Phone: 443-480-3673