Provider Demographics
NPI:1023502549
Name:WILLOW GROVE MENTAL HEALTH, INC.
Entity type:Organization
Organization Name:WILLOW GROVE MENTAL HEALTH, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:WAGGONER
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:720-262-9100
Mailing Address - Street 1:14211 E 4TH AVE # 3-138
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80011-8736
Mailing Address - Country:US
Mailing Address - Phone:720-262-9100
Mailing Address - Fax:720-262-9101
Practice Address - Street 1:14211 E 4TH AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80011-8736
Practice Address - Country:US
Practice Address - Phone:720-262-9100
Practice Address - Fax:720-262-9101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-18
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO099239921041C0700X
CO0770900363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty