Provider Demographics
NPI:1447874573
Name:CANTRELL, ASHLEY LYNNE-THERESA (MA, BCBA, LBA)
Entity type:Individual
Prefix:MS
First Name:ASHLEY
Middle Name:LYNNE-THERESA
Last Name:CANTRELL
Suffix:
Gender:F
Credentials:MA, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:666 E MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49032-9803
Mailing Address - Country:US
Mailing Address - Phone:269-241-2700
Mailing Address - Fax:
Practice Address - Street 1:666 E MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:MI
Practice Address - Zip Code:49032-9803
Practice Address - Country:US
Practice Address - Phone:269-241-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-04
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBACB88877156F00000X
MI1-21-48318103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No156F00000XEye and Vision Services ProvidersTechnician/Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1447874573Medicaid