=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336770841
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARA STRATTON LCPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2020
-----------------------------------------------------
Last Update Date | 07/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6201 W MAIN ST STE 120
-----------------------------------------------------
City | MARYVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62062-6870
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-208-1690
-----------------------------------------------------
Fax | 618-772-7200
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 208 GRAND RAPIDS LN
-----------------------------------------------------
City | EDWARDSVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62025-5965
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-972-4014
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 180.011855
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------