Healthcare Provider Details

I. General information

NPI: 1124676739
Provider Name (Legal Business Name): WILLOW HAVEN COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2019
Last Update Date: 08/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 S MAIN ST STE 100
LOGAN UT
84321-5203
US

IV. Provider business mailing address

1295 E 2100 N
NORTH LOGAN UT
84341-2035
US

V. Phone/Fax

Practice location:
  • Phone: 801-822-2109
  • Fax:
Mailing address:
  • Phone: 801-822-2109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MRS. ASHLEY CAROLINA BROG
Title or Position: MEMBER/THERAPIST
Credential: LCSW
Phone: 801-822-2109