Provider Demographics
NPI:1952883431
Name:WILLOW OAK THERAPY, PLLC
Entity Type:Organization
Organization Name:WILLOW OAK THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:COULL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, RPT-S
Authorized Official - Phone:919-619-5019
Mailing Address - Street 1:1016 IREDELL ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-4124
Mailing Address - Country:US
Mailing Address - Phone:919-619-5019
Mailing Address - Fax:
Practice Address - Street 1:3622 LYCKAN PKWY STE 6006
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-2539
Practice Address - Country:US
Practice Address - Phone:919-619-5019
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-31
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC006702251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health