Healthcare Provider Details

I. General information

NPI: 1093350027
Provider Name (Legal Business Name): MOLLY SUE LEDBETTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2019
Last Update Date: 10/06/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1106 N MERCHANT ST
EFFINGHAM IL
62401-2128
US

IV. Provider business mailing address

PO BOX 665
EFFINGHAM IL
62401-0665
US

V. Phone/Fax

Practice location:
  • Phone: 217-342-7000
  • Fax: 217-342-7002
Mailing address:
  • Phone: 217-690-5769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2019045706
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number240312
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.015565
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: