Provider Demographics
NPI:1376635102
Name:WILLOWDALE COUNSELING CENTER, PLLC
Entity type:Organization
Organization Name:WILLOWDALE COUNSELING CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:C
Authorized Official - Last Name:BRAY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:603-881-7554
Mailing Address - Street 1:76 NORTHEASTERN BLVD STE 36A
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03062-3196
Mailing Address - Country:US
Mailing Address - Phone:603-881-7554
Mailing Address - Fax:603-881-7533
Practice Address - Street 1:76 NORTHEASTERN BLVD STE 36A
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03062-3196
Practice Address - Country:US
Practice Address - Phone:603-881-7554
Practice Address - Fax:603-881-7533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH941103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty