Healthcare Provider Details

I. General information

NPI: 1275766222
Provider Name (Legal Business Name): BRENDA S ASHLEY BS, MHP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2009
Last Update Date: 08/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 E VINE ST
VIENNA IL
62995-1612
US

IV. Provider business mailing address

PO BOX 105
GOREVILLE IL
62939-0105
US

V. Phone/Fax

Practice location:
  • Phone: 618-658-2611
  • Fax:
Mailing address:
  • Phone: 618-751-0752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: