Provider Demographics
NPI:1356197487
Name:WILLOW BEHAVIOR SPECIALISTS
Entity type:Organization
Organization Name:WILLOW BEHAVIOR SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LACY
Authorized Official - Middle Name:M
Authorized Official - Last Name:WOLTER
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA, LBA
Authorized Official - Phone:262-337-2292
Mailing Address - Street 1:2400 NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-1922
Mailing Address - Country:US
Mailing Address - Phone:262-337-2292
Mailing Address - Fax:
Practice Address - Street 1:2400 NILES AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-1922
Practice Address - Country:US
Practice Address - Phone:262-337-2292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Multi-Specialty