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General NPI Number Information
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NPI Number | 1710466529
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Entity Type | Organization
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Legal Business Name | WILLOW CREEK WELLNESS LLC
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Dates
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Enumeration Date | 08/13/2018
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Last Update Date | 03/23/2022
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Provider Practice Location Address
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Address Line | 3630 SINTON RD STE 320
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City | COLORADO SPRINGS
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State | CO
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Zip | 80907-5070
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Country | US
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Telephone | 877-881-4551
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Fax | 719-960-2405
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Provider Business Mailing Address
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Address Line | 3630 SINTON RD STE 320
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City | COLORADO SPRINGS
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State | CO
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Zip | 80907-5070
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Country | US
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Telephone | 877-881-4551
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Fax | 719-960-2405
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Authorized Official
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Title or Position | OWNER
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Name | OWEN EUSTICE
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Credential | LCSW
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Telephone | 303-385-7920
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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 | 09924585
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License Number State | CO
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