Basic Information
| Provider Information | |||||||||
| NPI: | 1215357611 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILLOW TREE COUNELING AND EDUATIONAL CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10195 MAIN ST | ||||||||
| Address2: | SUITE N | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220313415 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 10195 MAIN ST | ||||||||
| Address2: | SUITE N | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220313415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7035919600 | ||||||||
| FaxNumber: | 7035919656 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2014 | ||||||||
| LastUpdateDate: | 04/24/2014 | ||||||||
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| AuthorizedOfficialLastName: | EVANS | ||||||||
| AuthorizedOfficialFirstName: | MARSHA | ||||||||
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| AuthorizedOfficialTitleorPosition: | LICENSED PROFESIONAL COUNSELOR | ||||||||
| AuthorizedOfficialTelephone: | 7035919600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 0701004932 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.