Provider Demographics
NPI:1912149345
Name:WILLOW TREE HEALING CENTER, LLC
Entity Type:Organization
Organization Name:WILLOW TREE HEALING CENTER, LLC
Other - Org Name:TRACEY WILKINS, LICSW, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CLINICAL SERVICES DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKINS
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:651-222-9985
Mailing Address - Street 1:1821 UNIVERSITY AVE
Mailing Address - Street 2:SUITE S329
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104
Mailing Address - Country:US
Mailing Address - Phone:651-222-9885
Mailing Address - Fax:888-977-2056
Practice Address - Street 1:1821 UNIVERSITY AVE W
Practice Address - Street 2:SUITE S329
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-2801
Practice Address - Country:US
Practice Address - Phone:651-222-9885
Practice Address - Fax:888-977-2056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-31
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN131191041C0700X
MN150431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN312174700Medicaid