Provider Demographics
NPI:1417278946
Name:WITHERS, ASHLY D
Entity Type:Individual
Prefix:
First Name:ASHLY
Middle Name:D
Last Name:WITHERS
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 1:300 SAN GABRIEL VILLAGE BLVD
Mailing Address - Street 2:424
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-6689
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1010 W JASPER DR
Practice Address - Street 2:SUITE 9
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-1331
Practice Address - Country:US
Practice Address - Phone:254-781-7397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-18
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX105341235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149984001Medicaid
TX149984001Medicaid