Provider Demographics
NPI:1528182896
Name:THE WILLOW GROUP, P.C.
Entity Type:Organization
Organization Name:THE WILLOW GROUP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:Y
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:712-323-1728
Mailing Address - Street 1:601 WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51501-4242
Mailing Address - Country:US
Mailing Address - Phone:712-323-1728
Mailing Address - Fax:712-323-8888
Practice Address - Street 1:601 WILLOW AVE
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-4242
Practice Address - Country:US
Practice Address - Phone:712-323-1728
Practice Address - Fax:712-323-8888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA116101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA=========Medicaid
IA=========Medicaid
IAI3640Medicare ID - Type Unspecified