Healthcare Provider Details

I. General information

NPI: 1801389051
Provider Name (Legal Business Name): MARY LOUISE SEXTON MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2018
Last Update Date: 06/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5230 6TH STREET FRONTAGE RD E
SPRINGFIELD IL
62703-5128
US

IV. Provider business mailing address

5230 6TH STREET FRONTAGE RD E
SPRINGFIELD IL
62703-5128
US

V. Phone/Fax

Practice location:
  • Phone: 217-585-4707
  • Fax: 217-585-4745
Mailing address:
  • Phone: 217-585-4707
  • Fax: 217-585-4745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: