Provider Demographics
NPI:1922795418
Name:PORTER, ASHLEY NICHOLE
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:NICHOLE
Last Name:PORTER
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 1:4705 OLD OAKS DR APT 2B
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-1469
Mailing Address - Country:US
Mailing Address - Phone:773-844-1723
Mailing Address - Fax:
Practice Address - Street 1:4705 OLD OAKS DR APT 2B
Practice Address - Street 2:
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-1469
Practice Address - Country:US
Practice Address - Phone:773-844-1723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.107002101YM0800X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health