Provider Demographics
NPI:1194857151
Name:BEITEL, ASHLEY HOWARD (PHD)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:HOWARD
Last Name:BEITEL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2804 ROBESON PARK DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-7600
Mailing Address - Country:US
Mailing Address - Phone:217-352-3591
Mailing Address - Fax:
Practice Address - Street 1:701 DEVONSHIRE DR STE 207
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7337
Practice Address - Country:US
Practice Address - Phone:217-352-9206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical