Healthcare Provider Details

I. General information

NPI: 1689277352
Provider Name (Legal Business Name): WILLOW LANE HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2020
Last Update Date: 01/07/2021
Certification Date: 01/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1288 BLUE LAKE DR
FRISCO TX
75033-1437
US

IV. Provider business mailing address

1288 BLUE LAKE DR
FRISCO TX
75033-1437
US

V. Phone/Fax

Practice location:
  • Phone: 828-506-0718
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: BRIAN FISHER
Title or Position: OWNER
Credential:
Phone: 214-385-0180