Provider Demographics
NPI:1578143327
Name:RED WILLOW THERAPY, LLC
Entity Type:Organization
Organization Name:RED WILLOW THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CURTIS
Authorized Official - Middle Name:
Authorized Official - Last Name:TINDALL
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:608-225-4002
Mailing Address - Street 1:415 LLANOS ST
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593-1945
Mailing Address - Country:US
Mailing Address - Phone:608-225-4002
Mailing Address - Fax:608-255-2752
Practice Address - Street 1:111 S 1ST ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-5244
Practice Address - Country:US
Practice Address - Phone:608-225-4002
Practice Address - Fax:608-255-2752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-14
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100053846Medicaid