Provider Demographics
NPI:1275945123
Name:ASH, GINA
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:ASH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8704 STATE ST
Mailing Address - Street 2:
Mailing Address - City:EAST SAINT LOUIS
Mailing Address - State:IL
Mailing Address - Zip Code:62203-2048
Mailing Address - Country:US
Mailing Address - Phone:618-207-3479
Mailing Address - Fax:
Practice Address - Street 1:8704 STATE ST
Practice Address - Street 2:
Practice Address - City:EAST SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62203-2048
Practice Address - Country:US
Practice Address - Phone:618-207-3479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-27
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-4215-0001-A101YA0400X
171M00000X
IL27122101YA0400X
016271101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator