Provider Demographics
NPI:1962720771
Name:THE WILLOW FOUNDATION
Entity type:Organization
Organization Name:THE WILLOW FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRITTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-578-0069
Mailing Address - Street 1:1405 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88203-5535
Mailing Address - Country:US
Mailing Address - Phone:575-578-0069
Mailing Address - Fax:
Practice Address - Street 1:1405 MADISON AVE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-5535
Practice Address - Country:US
Practice Address - Phone:575-578-0069
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-04
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness