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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1770232654
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLOW TREE PSYCHOTHERAPY

Provider Business Mailing Address
First Line	:	4043 RIVERDALE RD # 1076
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84405-1717
Country	:	US
Telephone Number	:	801-941-8283
Fax Number	:

Provider Business Practice Location Address
First Line	:	4043 RIVERDALE RD # 1076
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84405-1717
Country	:	US
Telephone Number	:	385-364-0321
Fax Number	:

Authorized Official
Title or Position	:	OWNER/CLINICIAN
Name	:	ELISABETH SAUCEDO
Credential	:	LCSW
Telephone Number	:	801-941-8283

Provider Enumeration Date	:	03/20/2022
Last Update Date	:	03/20/2022

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