MEDICARE: WILLOW TREE THERAPY

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	261QH0700X	Hearing and Speech Clinic/Center

General Provider Information

NPI Number	:	1467222752
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLOW TREE THERAPY

Provider Business Mailing Address
First Line	:	405 PIONEER DR UNIT 10
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91203-3825
Country	:	US
Telephone Number	:	818-370-5886
Fax Number	:

Provider Business Practice Location Address
First Line	:	405 PIONEER DR UNIT 10
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91203-3825
Country	:	US
Telephone Number	:	818-370-5886
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DESIREE SASUNIAN
Credential	:	CCC-SLP
Telephone Number	:	818-370-5886

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

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