Basic Information
| Provider Information | |||||||||
| NPI: | 1831478676 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IVY | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GILBERT | ||||||||
| OtherFirstName: | ASHLEY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 921 WEST BEACON STREET | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39350 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1301 WEST GOVERNMENT STREET | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | BRANDON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015917535 | ||||||||
| FaxNumber: | 6015917540 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2011 | ||||||||
| LastUpdateDate: | 04/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | S3609 | MS | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.