Basic Information
Provider Information | |||||||||
NPI: | 1376065953 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ATHEN | ||||||||
FirstName: | ASHLEIGH | ||||||||
MiddleName: | ROSE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LGSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | REYNOLDS | ||||||||
OtherFirstName: | ASHLEIGH | ||||||||
OtherMiddleName: | ROSE | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LGSW | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 7474 GREENWAY CENTER DR STE 730 | ||||||||
Address2: |   | ||||||||
City: | GREENBELT | ||||||||
State: | MD | ||||||||
PostalCode: | 207703523 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3013451022 | ||||||||
FaxNumber: | 3015605558 | ||||||||
Practice Location | |||||||||
Address1: | 1003 W SEVENTH ST STE 500 | ||||||||
Address2: |   | ||||||||
City: | FREDERICK | ||||||||
State: | MD | ||||||||
PostalCode: | 217018512 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3013451022 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/14/2017 | ||||||||
LastUpdateDate: | 07/14/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 21256 | MD | Y |   | Behavioral Health & Social Service Providers | Social Worker |   |
No ID Information.