Healthcare Provider Details

I. General information

NPI: 1225606239
Provider Name (Legal Business Name): ASHLEY MANDEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2021
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24402 W LOCKPORT ST STE 124
PLAINFIELD IL
60544-4288
US

IV. Provider business mailing address

24402 W LOCKPORT ST STE 124
PLAINFIELD IL
60544-4288
US

V. Phone/Fax

Practice location:
  • Phone: 815-239-0395
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-23-69306
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: