Basic Information
| Provider Information | |||||||||
| NPI: | 1114130135 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOSES | ||||||||
| FirstName: | ASHLEI | ||||||||
| MiddleName: | L | ||||||||
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| OtherLastName: | KOPEC | ||||||||
| OtherFirstName: | ASHLEI | ||||||||
| OtherMiddleName: | L | ||||||||
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| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 108 RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620625681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184029204 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 PERRYMAN ST | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622541356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185376165 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2007 | ||||||||
| LastUpdateDate: | 08/08/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 160.004743 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.