Healthcare Provider Details

I. General information

NPI: 1144807553
Provider Name (Legal Business Name): WILLOW TREE HEALING CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2021
Last Update Date: 11/08/2023
Certification Date: 03/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1516 NEWMOORE DR
GLOUCESTER VA
23061
US

IV. Provider business mailing address

6699 FOX CENTRE PKWY
GLOUCESTER VA
23061-6134
US

V. Phone/Fax

Practice location:
  • Phone: 252-619-0887
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MARY WILLOUGHBY PRENTISS
Title or Position: OWNER
Credential: LPC
Phone: 252-619-0887