Healthcare Provider Details

I. General information

NPI: 1225759020
Provider Name (Legal Business Name): ASHELY WHITAKER LCDC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ASHELY JOHNSON

II. Dates (important events)

Enumeration Date: 09/08/2022
Last Update Date: 09/08/2022
Certification Date: 09/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12613 SEATTLE SLEW DR APT 3304
JERSEY VILLAGE TX
77065-5529
US

IV. Provider business mailing address

12613 SEATTLE SLEW DR APT 3304
JERSEY VILLAGE TX
77065-5529
US

V. Phone/Fax

Practice location:
  • Phone: 214-223-0899
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number15129
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: