MEDICARE: WILLOW RIVER COUNSELING

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1932536794
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLOW RIVER COUNSELING

Provider Business Mailing Address
First Line	:	PO BOX 414
Second Line	:
City	:	CAMBRIDGE
State	:	MN
Zip	:	55008-0414
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6338 MAIN ST STE 9
Second Line	:
City	:	NORTH BRANCH
State	:	MN
Zip	:	55056-6693
Country	:	US
Telephone Number	:	763-607-5227
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KIMBERLY M BUNDY
Credential	:	MA
Telephone Number	:	763-607-5227

Provider Enumeration Date	:	10/10/2013
Last Update Date	:	10/10/2013

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