Provider Demographics
NPI:1801365234
Name:BLACK, ASHLEY NICOLE
Entity Type:Individual
Prefix:MRS
First Name:ASHLEY
Middle Name:NICOLE
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:ASHLEY
Other - Middle Name:NICOLE
Other - Last Name:WEST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:1101 W TOWNSHIP ROAD 150
Mailing Address - Street 2:
Mailing Address - City:TIFFIN
Mailing Address - State:OH
Mailing Address - Zip Code:44883-9446
Mailing Address - Country:US
Mailing Address - Phone:419-618-9202
Mailing Address - Fax:
Practice Address - Street 1:27 ST LAWRENCE DR STE 104
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-8313
Practice Address - Country:US
Practice Address - Phone:419-455-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-14
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.13448235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSP.13448OtherOHIO SPEECH LANGUAGE THERAPY LICENSE NUMBER
OHCOND.2018630-SPOtherOHIO SPEECH LANGUAGE THERAPY LICENSE NUMBER
14323703OtherASHA