MEDICARE: ASHLI SELF

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	235Z00000X	Speech-Language Pathologist	146012344	IL

General Provider Information

NPI Number	:	1174989453
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ASHLI SELF

Provider Business Mailing Address
First Line	:	5704 WONDER WOODS DR
Second Line	:
City	:	WONDER LAKE
State	:	IL
Zip	:	60097-9114
Country	:	US
Telephone Number	:	815-403-0485
Fax Number	:

Provider Business Practice Location Address
First Line	:	8600 US HIGHWAY 14
Second Line	:	STE 108
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60012-2700
Country	:	US
Telephone Number	:	815-403-0485
Fax Number	:	815-527-6037

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

Provider Enumeration Date	:	01/03/2016
Last Update Date	:	09/29/2017

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Directions to “ ASHLI SELF ” Practice Location

Language	Start Address	Practice Location

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