Provider Demographics
NPI:1518582584
Name:PRINCE, ASHTON (COTA)
Entity Type:Individual
Prefix:
First Name:ASHTON
Middle Name:
Last Name:PRINCE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 S RANDOLPH ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IL
Mailing Address - Zip Code:61356-1961
Mailing Address - Country:US
Mailing Address - Phone:815-915-5038
Mailing Address - Fax:
Practice Address - Street 1:680 W PERU ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356-6803
Practice Address - Country:US
Practice Address - Phone:815-343-0572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-15
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.005421224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant