Healthcare Provider Details

I. General information

NPI: 1679128946
Provider Name (Legal Business Name): SLOANE MIRANDA WOLTER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2019
Last Update Date: 07/11/2026
Certification Date: 07/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 W STATE ST
O FALLON IL
62269-1164
US

IV. Provider business mailing address

302 W STATE ST
O FALLON IL
62269-1164
US

V. Phone/Fax

Practice location:
  • Phone: 618-589-3028
  • Fax:
Mailing address:
  • Phone: 618-589-3028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number149.031968
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: