Basic Information
| Provider Information | |||||||||
| NPI: | 1194311423 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ASHWORTH | ||||||||
| FirstName: | STEVIE | ||||||||
| MiddleName: | BERLIN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PROBST | ||||||||
| OtherFirstName: | STEVIE | ||||||||
| OtherMiddleName: | BERLIN | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 402 S SILVER SPRINGS RD | ||||||||
| Address2: | |||||||||
| City: | CAPE GIRARDEAU | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637037536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733341100 | ||||||||
| FaxNumber: | 5736514345 | ||||||||
| Practice Location | |||||||||
| Address1: | 402 S SILVER SPRINGS RD | ||||||||
| Address2: | |||||||||
| City: | CAPE GIRARDEAU | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637037536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733341100 | ||||||||
| FaxNumber: | 5736514345 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2020 | ||||||||
| LastUpdateDate: | 10/20/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 2020041563 | MO | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 490094299 | 05 | MO | MEDICAID |