Basic Information
| Provider Information | |||||||||
| NPI: | 1356617203 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KNICELEY | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 915 | ||||||||
| Address2: | 555 TOWNER | ||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7345443000 | ||||||||
| FaxNumber: | 7345446732 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 TOWNER ST | ||||||||
| Address2: | |||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481985752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7345443050 | ||||||||
| FaxNumber: | 7345442906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2012 | ||||||||
| LastUpdateDate: | 05/07/2019 | ||||||||
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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 | 1041C0700X | L1669881 | MI | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 38-6004894 | 01 | MI | COUNTY OF WASHTENAW | OTHER |