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General NPI Number Information
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NPI Number | 1881372308
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Entity Type | Organization
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Legal Business Name | CITIED
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Dates
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Enumeration Date | 07/05/2023
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Last Update Date | 10/19/2023
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Provider Practice Location Address
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Address Line | 5301 E STATE ST STE 309A
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City | ROCKFORD
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State | IL
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Zip | 61108-2399
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Country | US
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Telephone | 608-713-3454
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Fax |
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Provider Business Mailing Address
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Address Line | 1907 JONATHAN AVE
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City | ROCKFORD
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State | IL
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Zip | 61103-2908
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Country | US
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Telephone | 815-621-3853
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Fax |
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Authorized Official
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Title or Position | SOLE PROPRIETOR
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Name | ASHTON RAE LOCKHART
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Credential |
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Telephone | 608-713-3454
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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