=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659240133
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILLOW BROOK COUNSELING AND WELLNESS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2025
-----------------------------------------------------
Last Update Date | 11/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11859 N CR 1650E
-----------------------------------------------------
City | HAVANA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62644-6890
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-308-2440
-----------------------------------------------------
Fax | 217-771-1670
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11859 N CR 1650E
-----------------------------------------------------
City | HAVANA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62644-6890
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-308-2440
-----------------------------------------------------
Fax | 217-771-1670
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER/OWNER
-----------------------------------------------------
Name | FAYTHE REYHAN FLINN
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 217-308-2440
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------