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General NPI Number Information
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NPI Number | 1528182896
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Entity Type | Organization
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Legal Business Name | THE WILLOW GROUP, P.C.
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Dates
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Enumeration Date | 03/19/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 601 WILLOW AVE
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City | COUNCIL BLUFFS
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State | IA
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Zip | 51501-4242
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Country | US
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Telephone | 712-323-1728
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Fax | 712-323-8888
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Provider Business Mailing Address
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Address Line | 601 WILLOW AVE
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City | COUNCIL BLUFFS
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State | IA
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Zip | 51501-4242
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Country | US
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Telephone | 712-323-1728
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Fax | 712-323-8888
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. GARY Y LARSEN
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Credential | PH.D.
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Telephone | 712-323-1728
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 116
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License Number State | IA
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