=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952191090
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHERVONTI NORMAN LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2025
-----------------------------------------------------
Last Update Date | 05/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 322 S BUCHANAN ST
-----------------------------------------------------
City | EDWARDSVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62025-2086
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-498-0190
-----------------------------------------------------
Fax | 618-417-6049
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 104 BAYBERRY CT APT A
-----------------------------------------------------
City | GLEN CARBON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62034-2945
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-975-1638
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 178.019744
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------