Provider Demographics
NPI:1386620581
Name:WILLOW OAK THERAPY CENTER, INC.
Entity type:Organization
Organization Name:WILLOW OAK THERAPY CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JODY
Authorized Official - Middle Name:TABNER
Authorized Official - Last Name:THAYER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-C
Authorized Official - Phone:301-251-8965
Mailing Address - Street 1:15701 CRABBS BRANCH WAY
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20855-2634
Mailing Address - Country:US
Mailing Address - Phone:301-251-8965
Mailing Address - Fax:301-251-0136
Practice Address - Street 1:15701 CRABBS BRANCH WAY
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20855-2634
Practice Address - Country:US
Practice Address - Phone:301-251-8965
Practice Address - Fax:301-251-0136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-20
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD125603300Medicaid
DC7726OtherBLUE CROSS BLUE SHIELD
MD5458AFOtherBCBS
MD125603300Medicaid