Healthcare Provider Details

I. General information

NPI: 1821844424
Provider Name (Legal Business Name): ASHLEY LACE WILSON CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2024
Last Update Date: 06/17/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28407 STATE ROUTE 7
MARIETTA OH
45750-5152
US

IV. Provider business mailing address

28407 STATE ROUTE 7
MARIETTA OH
45750-5152
US

V. Phone/Fax

Practice location:
  • Phone: 740-371-5476
  • Fax: 740-371-5494
Mailing address:
  • Phone: 304-699-8772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number188960
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberAPS.004633
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: