Provider Demographics
NPI:1992038079
Name:ASHLEY, DEIDRE
Entity Type:Individual
Prefix:
First Name:DEIDRE
Middle Name:
Last Name:ASHLEY
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 1:284 EAST KELLY
Mailing Address - Street 2:PO BOX 7331
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002
Mailing Address - Country:US
Mailing Address - Phone:307-690-5627
Mailing Address - Fax:
Practice Address - Street 1:640 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8642
Practice Address - Country:US
Practice Address - Phone:307-733-2046
Practice Address - Fax:307-733-6289
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-08
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY785101YM0800X, 1041C0700X
WY251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No251C00000XAgenciesDay Training, Developmentally Disabled Services