Healthcare Provider Details

I. General information

NPI: 1548040744
Provider Name (Legal Business Name): WILLOW TREE MENTAL HEALTH CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2023
Last Update Date: 02/11/2025
Certification Date: 02/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N5273 STATE HIGHWAY 27
LADYSMITH WI
54848-1101
US

IV. Provider business mailing address

PO BOX 234
LADYSMITH WI
54848-0234
US

V. Phone/Fax

Practice location:
  • Phone: 715-532-0281
  • Fax: 715-532-0399
Mailing address:
  • Phone: 715-532-0281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DEBRA KOLTIS
Title or Position: OFFICE MANAGER
Credential:
Phone: 715-497-6478