=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811325699
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILLOWTREE SUPPORTS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2013
-----------------------------------------------------
Last Update Date | 05/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23733 W 83RD TER
-----------------------------------------------------
City | SHAWNEE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66227-3142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-353-1970
-----------------------------------------------------
Fax | 191-327-3677
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23733 W 83RD TER
-----------------------------------------------------
City | SHAWNEE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66227-3142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-353-1970
-----------------------------------------------------
Fax | 191-327-3677
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | CONNIE J MORRIS
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 913-353-1970
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number | 14-42302-062
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------