Provider Demographics
NPI:1881372308
Name:CITIED
Entity type:Organization
Organization Name:CITIED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:ASHTON
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:LOCKHART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-713-3454
Mailing Address - Street 1:1907 JONATHAN AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61103-2908
Mailing Address - Country:US
Mailing Address - Phone:815-621-3853
Mailing Address - Fax:
Practice Address - Street 1:5301 E STATE ST STE 309A
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2399
Practice Address - Country:US
Practice Address - Phone:608-713-3454
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-05
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty