Provider Demographics
NPI:1568997054
Name:WILLOW PATH COUNSELING SERVICES
Entity Type:Organization
Organization Name:WILLOW PATH COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:269-355-0725
Mailing Address - Street 1:23939 FINCH AVE
Mailing Address - Street 2:
Mailing Address - City:MATTAWAN
Mailing Address - State:MI
Mailing Address - Zip Code:49071-8032
Mailing Address - Country:US
Mailing Address - Phone:269-355-0725
Mailing Address - Fax:
Practice Address - Street 1:5725 VENTURE PARK DR STE B
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-2816
Practice Address - Country:US
Practice Address - Phone:269-355-0725
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-22
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801091193251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health