MEDICARE: CITIED

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1881372308
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITIED

Provider Business Mailing Address
First Line	:	1907 JONATHAN AVE
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61103-2908
Country	:	US
Telephone Number	:	815-621-3853
Fax Number	:

Provider Business Practice Location Address
First Line	:	5301 E STATE ST STE 309A
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61108-2399
Country	:	US
Telephone Number	:	608-713-3454
Fax Number	:

Authorized Official
Title or Position	:	SOLE PROPRIETOR
Name	:	ASHTON RAE LOCKHART
Credential	:
Telephone Number	:	608-713-3454

Provider Enumeration Date	:	07/05/2023
Last Update Date	:	10/19/2023

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Directions to “CITIED ” Practice Location

Language	Start Address	Practice Location

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