Basic Information
| Provider Information | |||||||||
| NPI: | 1851889224 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DALE | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4427 EMERSON ST STE 4 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322074960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043987015 | ||||||||
| FaxNumber: | 9043460837 | ||||||||
| Practice Location | |||||||||
| Address1: | 4427 EMERSON ST STE 4 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322074960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043987015 | ||||||||
| FaxNumber: | 9043460837 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2018 | ||||||||
| LastUpdateDate: | 05/01/2018 | ||||||||
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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 | 106H00000X | IMT2691 | FL | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YA0400X | ADC-001791-2014 | FL | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.