Healthcare Provider Details

I. General information

NPI: 1831919331
Provider Name (Legal Business Name): SEGOLAME LEBOGANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2024
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 S WALL ST
CARBONDALE IL
62901-3240
US

IV. Provider business mailing address

1201 LOCUST ST
ELDORADO IL
62930-1722
US

V. Phone/Fax

Practice location:
  • Phone: 618-252-9036
  • Fax:
Mailing address:
  • Phone: 618-252-9036
  • Fax: 618-216-9993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: