Healthcare Provider Details

I. General information

NPI: 1629579313
Provider Name (Legal Business Name): STEPHANIE S SEXTON ED.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2018
Last Update Date: 02/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 DOUGLAS AVE NW
ROANOKE VA
24012-4611
US

IV. Provider business mailing address

40 DOUGLAS AVE NW
ROANOKE VA
24012-4611
US

V. Phone/Fax

Practice location:
  • Phone: 540-853-2466
  • Fax: 540-853-2469
Mailing address:
  • Phone: 540-853-2466
  • Fax: 540-853-2469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number0813000079
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: