MEDICARE: WILLOW INTEGRATIVE WELLNESS

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1225825490
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLOW INTEGRATIVE WELLNESS

Provider Business Mailing Address
First Line	:	216 E RIDGEWOOD AVE STE 3B
Second Line	:
City	:	RIDGEWOOD
State	:	NJ
Zip	:	07450-3849
Country	:	US
Telephone Number	:	551-288-6543
Fax Number	:	551-212-3041

Provider Business Practice Location Address
First Line	:	216 E RIDGEWOOD AVE STE 3B
Second Line	:
City	:	RIDGEWOOD
State	:	NJ
Zip	:	07450-3849
Country	:	US
Telephone Number	:	201-637-4345
Fax Number	:

Authorized Official
Title or Position	:	PSYCHIATRIC NURSE PRACTITIONER
Name	:	EMILY COYLE
Credential	:	PMHNP-BC
Telephone Number	:	551-288-6543

Provider Enumeration Date	:	04/22/2025
Last Update Date	:	02/18/2026

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