Basic Information
| Provider Information | |||||||||
| NPI: | 1013638154 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PORTELL | ||||||||
| FirstName: | ASHLAE | ||||||||
| MiddleName: | LAUREN | ||||||||
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| Credential: | TLLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 203 HEIDI CT | ||||||||
| Address2: | |||||||||
| City: | MOUNT PLEASANT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488581207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6168351964 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 301 S CRAPO ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | MOUNT PLEASANT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488582941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897725938 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2022 | ||||||||
| LastUpdateDate: | 09/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6352000630 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.