Healthcare Provider Details

I. General information

NPI: 1568090678
Provider Name (Legal Business Name): ASHLEY ICE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2020
Last Update Date: 03/26/2022
Certification Date: 03/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 CENTRAL AVE STE 17
HIGHLAND PARK IL
60035-3246
US

IV. Provider business mailing address

777 CENTRAL AVE STE 17
HIGHLAND PARK IL
60035-3246
US

V. Phone/Fax

Practice location:
  • Phone: 847-432-4981
  • Fax:
Mailing address:
  • Phone: 847-432-4981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.021581
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: