Provider Demographics
NPI:1326899220
Name:WILLOW WATERS THERAPY
Entity Type:Organization
Organization Name:WILLOW WATERS THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDERGRIEND
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:616-466-4776
Mailing Address - Street 1:103 COLLEGE AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5921
Mailing Address - Country:US
Mailing Address - Phone:616-466-4776
Mailing Address - Fax:
Practice Address - Street 1:103 COLLEGE AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5921
Practice Address - Country:US
Practice Address - Phone:616-466-4776
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty