Provider Demographics
NPI:1780742874
Name:WILLOWSTONE FAMILY SERVICES
Entity type:Organization
Organization Name:WILLOWSTONE FAMILY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:765-423-5361
Mailing Address - Street 1:615 N. 18TH ST.
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-3434
Mailing Address - Country:US
Mailing Address - Phone:765-423-5361
Mailing Address - Fax:765-742-8272
Practice Address - Street 1:615 N. 18TH ST.
Practice Address - Street 2:SUITE 101
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-3434
Practice Address - Country:US
Practice Address - Phone:765-423-5361
Practice Address - Fax:765-742-8272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100264050Medicaid
IN100445220AMedicaid
IN100264050Medicaid