Provider Demographics
NPI:1114602836
Name:GRESHAM, ASHONTA DEE (THERAPIST)
Entity Type:Individual
Prefix:
First Name:ASHONTA
Middle Name:DEE
Last Name:GRESHAM
Suffix:
Gender:F
Credentials:THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 ROBERTS DR STE E
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2913
Mailing Address - Country:US
Mailing Address - Phone:404-566-0035
Mailing Address - Fax:
Practice Address - Street 1:613 ROBERTS DR STE E
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2913
Practice Address - Country:US
Practice Address - Phone:404-566-0035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-20
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACOSA065559175F00000X, 207RG0100X, 171400000X, 175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
No175F00000XOther Service ProvidersNaturopath
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology