Healthcare Provider Details

I. General information

NPI: 1134828684
Provider Name (Legal Business Name): ASHLEY NICOLE TUCKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2023
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

377 W VIRGINIA ST
CRYSTAL LAKE IL
60014-5756
US

IV. Provider business mailing address

475 W TERRA COTTA AVE STE E
CRYSTAL LAKE IL
60014-3407
US

V. Phone/Fax

Practice location:
  • Phone: 815-707-4806
  • Fax: 815-977-8715
Mailing address:
  • Phone: 815-707-4806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.016345
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: