Provider Demographics
NPI:1821368515
Name:WILLOW PROFESSIONALS, LLC
Entity Type:Organization
Organization Name:WILLOW PROFESSIONALS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-483-3636
Mailing Address - Street 1:122 S PHILLIPS AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-6717
Mailing Address - Country:US
Mailing Address - Phone:605-332-5298
Mailing Address - Fax:605-332-5280
Practice Address - Street 1:122 S PHILLIPS AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-6717
Practice Address - Country:US
Practice Address - Phone:605-332-5298
Practice Address - Fax:605-332-5280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-11
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty