Provider Demographics
NPI:1790861086
Name:WELLNESS WILLOWS HOLISTIC HEALTH RETREAT INC
Entity type:Organization
Organization Name:WELLNESS WILLOWS HOLISTIC HEALTH RETREAT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MURRAY-WACHTENDORF
Authorized Official - Suffix:I
Authorized Official - Credentials:PSYD, LPC
Authorized Official - Phone:936-931-3324
Mailing Address - Street 1:16525 MATHIS RD
Mailing Address - Street 2:
Mailing Address - City:WALLER
Mailing Address - State:TX
Mailing Address - Zip Code:77484-4909
Mailing Address - Country:US
Mailing Address - Phone:936-931-3324
Mailing Address - Fax:832-553-7973
Practice Address - Street 1:16525 MATHIS RD
Practice Address - Street 2:
Practice Address - City:WALLER
Practice Address - State:TX
Practice Address - Zip Code:77484-4909
Practice Address - Country:US
Practice Address - Phone:936-931-3324
Practice Address - Fax:832-553-7973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-29
Last Update Date:2009-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63119261QM0850X, 102L00000X, 261QM0855X, 101YP2500X
TX332B00000X
TX1983261QS1200X
TXE6345261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalystGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXFTS191Medicare PIN