Provider Demographics
NPI:1053491571
Name:BRANCH, SALLY B (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:B
Last Name:BRANCH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 IVY CT
Mailing Address - Street 2:
Mailing Address - City:KENILWORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60043-1172
Mailing Address - Country:US
Mailing Address - Phone:847-251-6019
Mailing Address - Fax:
Practice Address - Street 1:5225 OLD ORCHARD RD
Practice Address - Street 2:SUITE29
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-4405
Practice Address - Country:US
Practice Address - Phone:847-251-6019
Practice Address - Fax:847-251-4037
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0053241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical