Provider Demographics
NPI:1083922405
Name:WILLOW, GRACE (NCTMB)
Entity Type:Individual
Prefix:MS
First Name:GRACE
Middle Name:
Last Name:WILLOW
Suffix:
Gender:F
Credentials:NCTMB
Other - Prefix:MS
Other - First Name:GRACE
Other - Middle Name:
Other - Last Name:VANDENBERG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:9430 PENINSULA DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-8387
Mailing Address - Country:US
Mailing Address - Phone:269-650-2172
Mailing Address - Fax:
Practice Address - Street 1:812 S GARFIELD AVE STE 1
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3456
Practice Address - Country:US
Practice Address - Phone:231-421-9201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-20
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist