Provider Demographics
NPI:1245848696
Name:WILLOW TREE WELLNESS, INC
Entity type:Organization
Organization Name:WILLOW TREE WELLNESS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:PIKALA
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:651-216-5309
Mailing Address - Street 1:4423 VIKING BLVD NE
Mailing Address - Street 2:
Mailing Address - City:EAST BETHEL
Mailing Address - State:MN
Mailing Address - Zip Code:55092-9494
Mailing Address - Country:US
Mailing Address - Phone:651-216-5309
Mailing Address - Fax:
Practice Address - Street 1:4423 VIKING BLVD NE
Practice Address - Street 2:
Practice Address - City:EAST BETHEL
Practice Address - State:MN
Practice Address - Zip Code:55092-9494
Practice Address - Country:US
Practice Address - Phone:651-216-5309
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty