Provider Demographics
NPI:1154437739
Name:WILLOW WELLNESS CENTER, PLLC
Entity type:Organization
Organization Name:WILLOW WELLNESS CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:CECILIA
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:847-318-8200
Mailing Address - Street 1:2604 DEMPSTER ST STE 402
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-8438
Mailing Address - Country:US
Mailing Address - Phone:847-318-8200
Mailing Address - Fax:224-478-0026
Practice Address - Street 1:2604 DEMPSTER ST STE 401
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-8428
Practice Address - Country:US
Practice Address - Phone:847-318-8200
Practice Address - Fax:224-478-0026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209629Medicare ID - Type UnspecifiedWILLOW WELLNESS CENTER ID