Provider Demographics
NPI:1649521584
Name:WILLOW TREE WELLNESS & COUNSELING, LLC
Entity type:Organization
Organization Name:WILLOW TREE WELLNESS & COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER & CHIEF CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:IACOVONI
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, MSW
Authorized Official - Phone:570-336-9921
Mailing Address - Street 1:214 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-1752
Mailing Address - Country:US
Mailing Address - Phone:570-336-9921
Mailing Address - Fax:570-317-2594
Practice Address - Street 1:214 CENTER ST
Practice Address - Street 2:
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-1752
Practice Address - Country:US
Practice Address - Phone:570-336-9921
Practice Address - Fax:570-317-2594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-01
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0171381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty