Provider Demographics
NPI:1669299533
Name:WILLARD, ASHLYN ALEXIS
Entity type:Individual
Prefix:
First Name:ASHLYN
Middle Name:ALEXIS
Last Name:WILLARD
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 1:3970 STOCKMAN RD
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-2004
Mailing Address - Country:US
Mailing Address - Phone:208-220-9517
Mailing Address - Fax:
Practice Address - Street 1:1800 GARRETT WAY STE 47
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5132
Practice Address - Country:US
Practice Address - Phone:208-595-6732
Practice Address - Fax:208-904-0792
Is Sole Proprietor?:No
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-454091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical