Provider Demographics
NPI:1730990078
Name:DERRY, ASHLEY JO (RBT-24-375583)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:JO
Last Name:DERRY
Suffix:
Gender:F
Credentials:RBT-24-375583
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 S FACTORY ST
Mailing Address - Street 2:
Mailing Address - City:FAIRMOUNT
Mailing Address - State:IN
Mailing Address - Zip Code:46928-1831
Mailing Address - Country:US
Mailing Address - Phone:765-661-8798
Mailing Address - Fax:
Practice Address - Street 1:605 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-3403
Practice Address - Country:US
Practice Address - Phone:765-382-8222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-16
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-24-375583103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst