MEDICARE: ASHLEY R CRILEY RBT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	RBT-19-81293	IL

General Provider Information

NPI Number	:	1033777925
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ASHLEY R CRILEY RBT

Provider Business Mailing Address
First Line	:	343 FOUNTAINS PKWY STE 201
Second Line	:
City	:	FAIRVIEW HEIGHTS
State	:	IL
Zip	:	62208-2170
Country	:	US
Telephone Number	:	618-515-1441
Fax Number	:	618-551-4711

Provider Business Practice Location Address
First Line	:	343 FOUNTAINS PKWY STE 201
Second Line	:
City	:	FAIRVIEW HEIGHTS
State	:	IL
Zip	:	62208-2170
Country	:	US
Telephone Number	:	618-515-1441
Fax Number	:	618-551-4711

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2019
Last Update Date	:	06/22/2020

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