Provider Demographics
NPI:1386331874
Name:WILLOW, MARIE CLAIR (CPS)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:CLAIR
Last Name:WILLOW
Suffix:
Gender:F
Credentials:CPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:ST STEPHENS
Mailing Address - State:WY
Mailing Address - Zip Code:82524-0190
Mailing Address - Country:US
Mailing Address - Phone:307-856-0470
Mailing Address - Fax:
Practice Address - Street 1:450 S FEDERAL BLVD
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-4711
Practice Address - Country:US
Practice Address - Phone:307-349-5045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY108175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist