Provider Demographics
NPI:1841742632
Name:WILLOW TREE COUNSELING LLC
Entity type:Organization
Organization Name:WILLOW TREE COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST COOWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BALDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LISW-CP
Authorized Official - Phone:864-436-9075
Mailing Address - Street 1:107 E PARK AVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-1631
Mailing Address - Country:US
Mailing Address - Phone:864-729-4184
Mailing Address - Fax:864-729-4044
Practice Address - Street 1:107 E PARK AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-1631
Practice Address - Country:US
Practice Address - Phone:864-729-4184
Practice Address - Fax:864-729-4044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC105111041C0700X
SC101381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSW1324Medicaid
SCSW1327Medicaid