Healthcare Provider Details

I. General information

NPI: 1093096588
Provider Name (Legal Business Name): MICHELLE L. BUXTON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2011
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 DEVONSHIRE DR STE 139
CHAMPAIGN IL
61820-7337
US

IV. Provider business mailing address

2303 IRONWOOD CIR
CHAMPAIGN IL
61822-9299
US

V. Phone/Fax

Practice location:
  • Phone: 217-255-2795
  • Fax:
Mailing address:
  • Phone: 217-649-8479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149012607
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: