Provider Demographics
NPI:1467020891
Name:WILLOW GRACE WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:WILLOW GRACE WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPITST
Authorized Official - Prefix:MRS
Authorized Official - First Name:TANGIE
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:MACON
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LICSW, PIP
Authorized Official - Phone:205-613-0764
Mailing Address - Street 1:2028 KENTUCKY AVE STE 101&103
Mailing Address - Street 2:
Mailing Address - City:VESTAVIA HILLS
Mailing Address - State:AL
Mailing Address - Zip Code:35216-1946
Mailing Address - Country:US
Mailing Address - Phone:205-613-0764
Mailing Address - Fax:
Practice Address - Street 1:2028 KENTUCKY AVE STE 101&103
Practice Address - Street 2:
Practice Address - City:VESTAVIA HILLS
Practice Address - State:AL
Practice Address - Zip Code:35216-1946
Practice Address - Country:US
Practice Address - Phone:205-613-0764
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-13
Last Update Date:2021-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty