Provider Demographics
NPI:1922725472
Name:WILLOW RIVER WELLNESS, LLC
Entity Type:Organization
Organization Name:WILLOW RIVER WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:FOREMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-313-0069
Mailing Address - Street 1:5775 AVISTA DR
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34243-3616
Mailing Address - Country:US
Mailing Address - Phone:352-238-0974
Mailing Address - Fax:
Practice Address - Street 1:5775 AVISTA DR
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34243-3616
Practice Address - Country:US
Practice Address - Phone:352-238-0974
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty