Provider Demographics
NPI:1215560040
Name:PHELPS, ASHLEY MELYN (CTRS, CBIS)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MELYN
Last Name:PHELPS
Suffix:
Gender:F
Credentials:CTRS, CBIS
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:MELYN
Other - Last Name:DESSAINT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CTRS, CBIS
Mailing Address - Street 1:6714 NORTHLAND DR NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-9201
Mailing Address - Country:US
Mailing Address - Phone:616-450-9476
Mailing Address - Fax:
Practice Address - Street 1:6714 NORTHLAND DR NE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-9201
Practice Address - Country:US
Practice Address - Phone:616-450-9476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-20
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI63196225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist