Provider Demographics
NPI:1073352332
Name:WILLOW STREAM LLC
Entity type:Organization
Organization Name:WILLOW STREAM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MISA
Authorized Official - Middle Name:
Authorized Official - Last Name:YANAGISAWA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, LCSWC
Authorized Official - Phone:844-647-2926
Mailing Address - Street 1:233 E SOUTHERN AVE UNIT 25237
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85285-0076
Mailing Address - Country:US
Mailing Address - Phone:844-647-2926
Mailing Address - Fax:
Practice Address - Street 1:233 E SOUTHERN AVE UNIT 25237
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85285-0076
Practice Address - Country:US
Practice Address - Phone:844-647-2926
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-24
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)