=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154139251
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ASHLEY MCNABB
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2024
-----------------------------------------------------
Last Update Date | 12/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 835 MASON ST STE B220
-----------------------------------------------------
City | DEARBORN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48124-2262
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-561-9064
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1805 3RD ST
-----------------------------------------------------
City | WYANDOTTE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48192-4001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 6451024094
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 6451024094
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------