1912149345 NPI number — WILLOW TREE HEALING CENTER, LLC

Table of content: (NPI 1912149345)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912149345 NPI number — WILLOW TREE HEALING CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLOW TREE HEALING CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
TRACEY WILKINS, LICSW, LLC
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912149345
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1821 UNIVERSITY AVE
Provider Second Line Business Mailing Address:
SUITE S329
Provider Business Mailing Address City Name:
ST PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-222-9885
Provider Business Mailing Address Fax Number:
888-977-2056

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1821 UNIVERSITY AVE W
Provider Second Line Business Practice Location Address:
SUITE S329
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55104-2801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-222-9885
Provider Business Practice Location Address Fax Number:
888-977-2056
Provider Enumeration Date:
03/31/2009

Additional Information

Authorized Official

Authorized Official Last Name:
WILKINS
Authorized Official First Name:
TRACEY
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINICAL SERVICES DIRECTOR
Authorized Official Telephone Number:
651-222-9985

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  13119 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X , with the licence number: 15043 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 312174700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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