Provider Demographics
NPI:1295244127
Name:WILLOW HARBOR THERAPY CENTER, LLC
Entity type:Organization
Organization Name:WILLOW HARBOR THERAPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SABRINA
Authorized Official - Middle Name:IRENE
Authorized Official - Last Name:CONKLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DSW, LCSW
Authorized Official - Phone:850-776-6297
Mailing Address - Street 1:1010 N 12TH AVE STE 321
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32501-3370
Mailing Address - Country:US
Mailing Address - Phone:850-776-6297
Mailing Address - Fax:
Practice Address - Street 1:1010 N 12TH AVE STE 321
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-3370
Practice Address - Country:US
Practice Address - Phone:850-776-6297
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW12317101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty