Provider Demographics
NPI:1649420514
Name:SEXTON, SUSAN MARIE (MA LP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:SEXTON
Suffix:
Gender:F
Credentials:MA LP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:WIMMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LP
Mailing Address - Street 1:218 FAIRVIEW AVENUE SOUTH
Mailing Address - Street 2:
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105
Mailing Address - Country:US
Mailing Address - Phone:651-246-3372
Mailing Address - Fax:952-361-1660
Practice Address - Street 1:1145 GRAND AVENUE
Practice Address - Street 2:#201
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105
Practice Address - Country:US
Practice Address - Phone:651-246-3372
Practice Address - Fax:952-361-1660
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-26
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4934103TC1900X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling