Provider Demographics
NPI:1942879176
Name:CLARK, ASHLEY RAE (CASE MANAGER)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:RAE
Last Name:CLARK
Suffix:
Gender:F
Credentials:CASE MANAGER
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:RAE
Other - Last Name:FIRLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 55
Mailing Address - Street 2:
Mailing Address - City:WALTON
Mailing Address - State:KY
Mailing Address - Zip Code:41094-0055
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:188 W HEBBLE AVE
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-4960
Practice Address - Country:US
Practice Address - Phone:513-594-0583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-22
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator