Basic Information
| Provider Information | |||||||||
| NPI: | 1245822782 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GALLAHER | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | L | ||||||||
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| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JUETTE | ||||||||
| OtherFirstName: | ASHLEY | ||||||||
| OtherMiddleName: | L | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1601 OLD SOUTH RIVER RD | ||||||||
| Address2: | |||||||||
| City: | SAINT CHARLES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633034120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362241210 | ||||||||
| FaxNumber: | 6362461008 | ||||||||
| Practice Location | |||||||||
| Address1: | 639 YORK ST RM 212 | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623013919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2712226277 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2021 | ||||||||
| LastUpdateDate: | 02/05/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 2019035896 | MO | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 178015678 | IL | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.