MEDICARE: WILLOW FAMILY HEALTH, INC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	103T00000X	Psychologist
2	101YM0800X	Mental Health Counselor
3	101YS0200X	School Counselor
4	103TC2200X	Clinical Child & Adolescent Psychologist
5	103TF0000X	Family Psychologist
6	103TP2701X	Group Psychotherapy Psychologist
7	103TS0200X	School Psychologist
8	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1346953460
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLOW FAMILY HEALTH, INC

Provider Business Mailing Address
First Line	:	12843 LANDALE ST
Second Line	:
City	:	STUDIO CITY
State	:	CA
Zip	:	91604-1352
Country	:	US
Telephone Number	:	818-533-2319
Fax Number	:

Provider Business Practice Location Address
First Line	:	12843 LANDALE ST
Second Line	:
City	:	STUDIO CITY
State	:	CA
Zip	:	91604-1352
Country	:	US
Telephone Number	:	818-533-2319
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOSHUA WYNER
Credential	:	LMFT
Telephone Number	:	818-533-2319

Provider Enumeration Date	:	01/04/2023
Last Update Date	:	03/02/2023

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