Provider Demographics
NPI:1760627236
Name:BRACK, ASHLEY ANNE
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:ANNE
Last Name:BRACK
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 1:765 ALLENS AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-5443
Mailing Address - Country:US
Mailing Address - Phone:401-444-3201
Mailing Address - Fax:401-444-8507
Practice Address - Street 1:765 ALLENS AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-5443
Practice Address - Country:US
Practice Address - Phone:401-444-3201
Practice Address - Fax:401-444-8507
Is Sole Proprietor?:No
Enumeration Date:2008-12-11
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RISP01040235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RISP01040OtherLICENSE