Provider Demographics
NPI:1851784003
Name:WILLOW CREEK COUNSELING ASSOCIATES, LLC
Entity Type:Organization
Organization Name:WILLOW CREEK COUNSELING ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JULI
Authorized Official - Middle Name:K
Authorized Official - Last Name:WALLIN-FISGUS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW LCSW
Authorized Official - Phone:307-751-9090
Mailing Address - Street 1:245 BROADWAY, STE 11
Mailing Address - Street 2:PO BOX 6650
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801
Mailing Address - Country:US
Mailing Address - Phone:307-751-9090
Mailing Address - Fax:
Practice Address - Street 1:2161 COFFEEN AVE STE 401
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-5771
Practice Address - Country:US
Practice Address - Phone:307-751-9090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-12
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLCSW 816101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty