Provider Demographics
NPI:1174377923
Name:STALLWORTH, ASHLEY Y
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:Y
Last Name:STALLWORTH
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 1:1745 JOURNEY FORTH TRL
Mailing Address - Street 2:
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-0499
Mailing Address - Country:US
Mailing Address - Phone:601-701-8054
Mailing Address - Fax:
Practice Address - Street 1:1050 SW 6TH AVE STE 1100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97204-1153
Practice Address - Country:US
Practice Address - Phone:972-379-9171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-16
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health