=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134007164
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILLSON THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2025
-----------------------------------------------------
Last Update Date | 08/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 JEFFERSON DR
-----------------------------------------------------
City | MENLO PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94025-1114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-800-3797
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 JEFFERSON DR
-----------------------------------------------------
City | MENLO PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94025-1114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-800-3797
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. ANDREA TERESA WILLSON
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 650-800-3797
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------