1932414026 NPI number — MRS. ASHLEY RAE MITICH EDD, LCPC, NCC

Table of content: MRS. ASHLEY RAE MITICH EDD, LCPC, NCC (NPI 1932414026)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932414026 NPI number — MRS. ASHLEY RAE MITICH EDD, LCPC, NCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MITICH
Provider First Name:
ASHLEY
Provider Middle Name:
RAE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
EDD, LCPC, NCC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COSENTINO
Provider Other First Name:
ASHLEY
Provider Other Middle Name:
RAE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1932414026
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15004 S. BARTLETT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLAINFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60544
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-325-3628
Provider Business Mailing Address Fax Number:
708-226-0040

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15915 CRYSTAL CREEK DR
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
HOMER GLEN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60491
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-529-6976
Provider Business Practice Location Address Fax Number:
708-226-0010
Provider Enumeration Date:
08/12/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  180.010649 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101Y00000X , with the licence number: 178.006788 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 180.010649 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1622805 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".