Provider Demographics
NPI:1992254452
Name:WILLOW TREE MENTAL HEALTH CENTER, LLC
Entity type:Organization
Organization Name:WILLOW TREE MENTAL HEALTH CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:636-695-2690
Mailing Address - Street 1:2123 ROSELAKE CIR
Mailing Address - Street 2:
Mailing Address - City:COTTLEVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63376-7772
Mailing Address - Country:US
Mailing Address - Phone:615-785-5124
Mailing Address - Fax:
Practice Address - Street 1:9979 WINGHAVEN BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-3627
Practice Address - Country:US
Practice Address - Phone:636-695-2690
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-26
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
MO20110401502084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty