Provider Demographics
NPI:1063967008
Name:WILLOW TREE THERAPY LLC
Entity type:Organization
Organization Name:WILLOW TREE THERAPY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:RAYNE
Authorized Official - Last Name:ABERCROMBIE
Authorized Official - Suffix:
Authorized Official - Credentials:LSCSW
Authorized Official - Phone:620-603-6257
Mailing Address - Street 1:1819 11TH STR.
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-4511
Mailing Address - Country:US
Mailing Address - Phone:620-603-6257
Mailing Address - Fax:620-603-6259
Practice Address - Street 1:1819 11TH STR.
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-4511
Practice Address - Country:US
Practice Address - Phone:620-603-6257
Practice Address - Fax:620-603-6259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-19
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS42221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200629070AMedicaid