=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134751753
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILLOW TREE THERAPY SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2020
-----------------------------------------------------
Last Update Date | 02/11/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19 W MACCLENNY AVE STE 111
-----------------------------------------------------
City | MACCLENNY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32063-2086
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-349-5299
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19 W MACCLENNY AVE STE 111
-----------------------------------------------------
City | MACCLENNY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32063-2086
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-349-5299
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | AMANDA N BAILEY
-----------------------------------------------------
Credential | LMHC
-----------------------------------------------------
Telephone | 423-337-1635
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------