Provider Demographics
NPI:1518350370
Name:WILLOW TREE LIFE COUNSELING LLC
Entity Type:Organization
Organization Name:WILLOW TREE LIFE COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:GERARDINE
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:WAGGLE
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:317-902-6724
Mailing Address - Street 1:5660 CAITO DR STE 122
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46226-1364
Mailing Address - Country:US
Mailing Address - Phone:317-902-6724
Mailing Address - Fax:317-377-3103
Practice Address - Street 1:10830 MEADOW LAKE DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46229-3500
Practice Address - Country:US
Practice Address - Phone:317-902-6724
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-17
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005160A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty