Healthcare Provider Details

I. General information

NPI: 1164175816
Provider Name (Legal Business Name): GRACE ELLEN SEXTON LPC, ATR-P
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2022
Last Update Date: 02/02/2022
Certification Date: 02/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2804 W BELMONT AVE STE 103
CHICAGO IL
60618-5879
US

IV. Provider business mailing address

1133 SOUTH BLVD APT 715
OAK PARK IL
60302-3285
US

V. Phone/Fax

Practice location:
  • Phone: 224-504-9854
  • Fax:
Mailing address:
  • Phone: 660-988-0973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178.017110
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: