Provider Demographics
NPI:1245069616
Name:WILLOW TREE LICENSED CLINICAL SOCIAL WORKER
Entity type:Organization
Organization Name:WILLOW TREE LICENSED CLINICAL SOCIAL WORKER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SIBELIA
Authorized Official - Middle Name:LISANNE
Authorized Official - Last Name:CHAIYAHAT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:442-500-8548
Mailing Address - Street 1:2103 S EL CAMINO REAL STE 202
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054-6281
Mailing Address - Country:US
Mailing Address - Phone:442-500-8548
Mailing Address - Fax:
Practice Address - Street 1:2103 S EL CAMINO REAL STE 206
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-6281
Practice Address - Country:US
Practice Address - Phone:442-500-8548
Practice Address - Fax:760-400-8379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-01
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty