Healthcare Provider Details

I. General information

NPI: 1457869794
Provider Name (Legal Business Name): ASHLEY STALTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2018
Last Update Date: 01/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13136 WESTERN AVE
BLUE ISLAND IL
60406-2423
US

IV. Provider business mailing address

14913 S CLEVELAND AVE
POSEN IL
60469-1538
US

V. Phone/Fax

Practice location:
  • Phone: 708-974-5800
  • Fax:
Mailing address:
  • Phone: 708-639-3206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: