Provider Demographics
NPI:1255011185
Name:ASHLEY, OLUWAGBOTEMI AYOMIDE (ICC)
Entity type:Individual
Prefix:
First Name:OLUWAGBOTEMI
Middle Name:AYOMIDE
Last Name:ASHLEY
Suffix:
Gender:F
Credentials:ICC
Other - Prefix:
Other - First Name:TEMI
Other - Middle Name:
Other - Last Name:ASHLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11 N LEYDEN ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-3858
Mailing Address - Country:US
Mailing Address - Phone:617-480-4164
Mailing Address - Fax:
Practice Address - Street 1:300 BATTLES ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-2231
Practice Address - Country:US
Practice Address - Phone:508-587-2579
Practice Address - Fax:508-583-8046
Is Sole Proprietor?:No
Enumeration Date:2023-07-25
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator