MEDICARE: WILLOW TREE LICENSED CLINICAL SOCIAL WORKER

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1245069616
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLOW TREE LICENSED CLINICAL SOCIAL WORKER

Provider Business Mailing Address
First Line	:	2103 S EL CAMINO REAL STE 202
Second Line	:
City	:	OCEANSIDE
State	:	CA
Zip	:	92054-6281
Country	:	US
Telephone Number	:	442-500-8548
Fax Number	:

Provider Business Practice Location Address
First Line	:	2103 S EL CAMINO REAL STE 202
Second Line	:
City	:	OCEANSIDE
State	:	CA
Zip	:	92054-6281
Country	:	US
Telephone Number	:	442-500-8548
Fax Number	:	760-400-8379

Authorized Official
Title or Position	:	CEO
Name	:	DR. SIBELIA LISANNE CHAIYAHAT
Credential	:	LCSW
Telephone Number	:	442-500-8548

Provider Enumeration Date	:	08/01/2024
Last Update Date	:	01/06/2026

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Directions to “WILLOW TREE LICENSED CLINICAL SOCIAL WORKER ” Practice Location

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