Provider Demographics
NPI:1114130135
Name:MOSES, ASHLEI L
Entity Type:Individual
Prefix:
First Name:ASHLEI
Middle Name:L
Last Name:MOSES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ASHLEI
Other - Middle Name:L
Other - Last Name:KOPEC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:108 RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-5681
Mailing Address - Country:US
Mailing Address - Phone:618-402-9204
Mailing Address - Fax:
Practice Address - Street 1:1 PERRYMAN ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IL
Practice Address - Zip Code:62254-1356
Practice Address - Country:US
Practice Address - Phone:618-537-6165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2009-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.004743225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant