MEDICARE: WILLOW STRENGTH FAMILY THERAPY, LLC

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	077411	IA

General Provider Information

NPI Number	:	1902384639
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLOW STRENGTH FAMILY THERAPY, LLC

Provider Business Mailing Address
First Line	:	2300 SWAN LAKE BLVD STE 102
Second Line	:
City	:	INDEPENDENCE
State	:	IA
Zip	:	50644-9708
Country	:	US
Telephone Number	:	563-212-8015
Fax Number	:

Provider Business Practice Location Address
First Line	:	2300 SWAN LAKE BLVD
Second Line	:	SUITE 102
City	:	INDEPENDENCE
State	:	IA
Zip	:	50644-5064
Country	:	US
Telephone Number	:	563-212-8015
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST/OWNER
Name	:	LAUREN OLDAG
Credential	:	LISW
Telephone Number	:	563-212-8015

Provider Enumeration Date	:	08/03/2018
Last Update Date	:	08/03/2018

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