Provider Demographics
NPI:1265668214
Name:ASHLEY PROFESSIONAL HOME SERVICES
Entity Type:Organization
Organization Name:ASHLEY PROFESSIONAL HOME SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:I
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-892-8868
Mailing Address - Street 1:183 AVE UNIVERSIDAD INTERAMERICA STE 204
Mailing Address - Street 2:
Mailing Address - City:SAN GERMAN
Mailing Address - State:PR
Mailing Address - Zip Code:00683-4459
Mailing Address - Country:US
Mailing Address - Phone:787-892-8868
Mailing Address - Fax:
Practice Address - Street 1:183 AVE UNIVERSIDAD INTERAMERICA STE 204
Practice Address - Street 2:
Practice Address - City:SAN GERMAN
Practice Address - State:PR
Practice Address - Zip Code:00683-4459
Practice Address - Country:US
Practice Address - Phone:787-892-8868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-04
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1879103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty