Healthcare Provider Details

I. General information

NPI: 1912776253
Provider Name (Legal Business Name): WILLOW COUNSELING AND THERAPEUTIC ART CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2023
Last Update Date: 05/21/2024
Certification Date: 05/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 N SHERMAN AVE STE 24
MADISON WI
53704-4457
US

IV. Provider business mailing address

615 N SHERMAN AVE STE 24
MADISON WI
53704-4457
US

V. Phone/Fax

Practice location:
  • Phone: 608-445-2510
  • Fax: 262-293-9777
Mailing address:
  • Phone: 608-445-2510
  • Fax: 262-293-9777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: DAWN M LIBERSKI
Title or Position: OFFICE MANAGER
Credential:
Phone: 414-426-8910