Healthcare Provider Details

I. General information

NPI: 1457288367
Provider Name (Legal Business Name): ASHLEY SOUTHCOMB
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1479 PLANTAIN DR
MINOOKA IL
60447-8215
US

IV. Provider business mailing address

1479 PLANTAIN DR
MINOOKA IL
60447-8215
US

V. Phone/Fax

Practice location:
  • Phone: 815-600-5146
  • Fax:
Mailing address:
  • Phone: 815-600-5146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178.022227
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: