Healthcare Provider Details

I. General information

NPI: 1386009009
Provider Name (Legal Business Name): ASHLEY ALLIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2015
Last Update Date: 11/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

708 CHURCH ST SUITE 221
EVANSTON IL
60201-3875
US

IV. Provider business mailing address

708 CHURCH ST SUITE 221
EVANSTON IL
60201-3875
US

V. Phone/Fax

Practice location:
  • Phone: 262-215-6506
  • Fax:
Mailing address:
  • Phone: 262-215-6506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180009592
License Number StateIL

VIII. Authorized Official

Name: ASHLEY ALLIS
Title or Position: THERAPIST
Credential: LCPC
Phone: 262-215-6506