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General NPI Number Information
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NPI Number | 1912149345
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Entity Type | Organization
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Legal Business Name | WILLOW TREE HEALING CENTER, LLC
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Dates
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Enumeration Date | 03/31/2009
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Last Update Date | 02/19/2015
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Provider Practice Location Address
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Address Line | 1821 UNIVERSITY AVE W SUITE S329
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City | SAINT PAUL
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State | MN
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Zip | 55104-2801
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Country | US
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Telephone | 651-222-9885
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Fax | 888-977-2056
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Provider Business Mailing Address
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Address Line | 1821 UNIVERSITY AVE SUITE S329
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City | ST PAUL
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State | MN
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Zip | 55104
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Country | US
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Telephone | 651-222-9885
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Fax | 888-977-2056
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Authorized Official
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Title or Position | CLINICAL SERVICES DIRECTOR
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Name | TRACEY WILKINS
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Credential | LICSW
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Telephone | 651-222-9985
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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 | 15043
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 13119
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License Number State | MN
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