Provider Demographics
NPI:1780107706
Name:WILLOW OF WONDER CHILD & FAMILY THERAPY PLLC
Entity type:Organization
Organization Name:WILLOW OF WONDER CHILD & FAMILY THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:KONARZ
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:586-291-1899
Mailing Address - Street 1:35587 BROOKE CT
Mailing Address - Street 2:
Mailing Address - City:NEW BALTIMORE
Mailing Address - State:MI
Mailing Address - Zip Code:48047-1137
Mailing Address - Country:US
Mailing Address - Phone:586-291-1899
Mailing Address - Fax:586-273-0107
Practice Address - Street 1:35218 23 MILE RD
Practice Address - Street 2:
Practice Address - City:NEW BALTIMORE
Practice Address - State:MI
Practice Address - Zip Code:48047-3650
Practice Address - Country:US
Practice Address - Phone:586-291-1899
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-21
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010838011041C0700X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICVO138370Medicaid