Provider Demographics
NPI:1386847515
Name:WILLOW BRIDGE RECOVERY, LLC
Entity Type:Organization
Organization Name:WILLOW BRIDGE RECOVERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-357-3466
Mailing Address - Street 1:PO BOX 56
Mailing Address - Street 2:
Mailing Address - City:LONG PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:56347-0056
Mailing Address - Country:US
Mailing Address - Phone:320-357-3466
Mailing Address - Fax:320-357-3468
Practice Address - Street 1:17 2ND ST N
Practice Address - Street 2:
Practice Address - City:LONG PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:56347-1117
Practice Address - Country:US
Practice Address - Phone:320-357-3466
Practice Address - Fax:320-357-3468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 251B00000X, 251S00000X, 261Q00000X, 261QR0405X, 324500000X
MN1039454-1-CRF3245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1107320OtherNON RESIDENTIAL SUD TREATMENT PROGRAM
MN026491100OtherCHILDRENS RESIDENTIAL