MEDICARE: WILLOW TREE PSYCHOTHERAPY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1427695089	OTHER		NPI

General Provider Information

NPI Number	:	1134988579
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLOW TREE PSYCHOTHERAPY

Provider Business Mailing Address
First Line	:	13 PINE ACRES DR
Second Line	:
City	:	CANTON
State	:	CT
Zip	:	06019-2135
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	13 PINE ACRES DR
Second Line	:
City	:	CANTON
State	:	CT
Zip	:	06019-2135
Country	:	US
Telephone Number	:	203-558-8214
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ADELA BAJRAKTAREVIC
Credential	:
Telephone Number	:	203-558-8214

Provider Enumeration Date	:	03/18/2024
Last Update Date	:	03/18/2024

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Directions to “WILLOW TREE PSYCHOTHERAPY ” Practice Location

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