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General NPI Number Information
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NPI Number | 1649521584
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Entity Type | Organization
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Legal Business Name | WILLOW TREE WELLNESS & COUNSELING, LLC
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Dates
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Enumeration Date | 10/01/2012
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Last Update Date | 10/01/2012
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Provider Practice Location Address
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Address Line | 214 CENTER ST
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City | BLOOMSBURG
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State | PA
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Zip | 17815-1752
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Country | US
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Telephone | 570-336-9921
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Fax | 570-317-2594
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Provider Business Mailing Address
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Address Line | 214 CENTER ST
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City | BLOOMSBURG
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State | PA
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Zip | 17815-1752
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Country | US
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Telephone | 570-336-9921
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Fax | 570-317-2594
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Authorized Official
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Title or Position | FOUNDER & CHIEF CLINICIAN
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Name | NICOLE IACOVONI
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Credential | LCSW, MSW
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Telephone | 570-336-9921
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | CW017138
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License Number State | PA
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