Healthcare Provider Details

I. General information

NPI: 1649420514
Provider Name (Legal Business Name): SUSAN MARIE SEXTON MA LP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SUSAN MARIE WIMMER M.A., L.P.

II. Dates (important events)

Enumeration Date: 09/26/2008
Last Update Date: 04/18/2022
Certification Date: 04/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1145 GRAND AVENUE #201
ST PAUL MN
55105
US

IV. Provider business mailing address

218 FAIRVIEW AVENUE SOUTH
ST PAUL MN
55105
US

V. Phone/Fax

Practice location:
  • Phone: 651-246-3372
  • Fax: 952-361-1660
Mailing address:
  • Phone: 651-246-3372
  • Fax: 952-361-1660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberLP4934
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP4934
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: