Provider Demographics
NPI:1609609833
Name:ANSELMO, ASHTON (EDS)
Entity type:Individual
Prefix:
First Name:ASHTON
Middle Name:
Last Name:ANSELMO
Suffix:
Gender:X
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8901 FLORENCE RD LOT 2060
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-7522
Mailing Address - Country:US
Mailing Address - Phone:931-334-3084
Mailing Address - Fax:
Practice Address - Street 1:220 ATHENS WAY STE 104
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37228-1351
Practice Address - Country:US
Practice Address - Phone:877-641-1155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-22
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6684101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health