Provider Demographics
NPI:1073712626
Name:SULLIVAN-RICE, BRENDA (LCSW)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:SULLIVAN-RICE
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 1:1102 MAKSIN RD
Mailing Address - Street 2:
Mailing Address - City:ELKVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62932-2220
Mailing Address - Country:US
Mailing Address - Phone:618-559-5035
Mailing Address - Fax:
Practice Address - Street 1:1102 MAKSIN RD
Practice Address - Street 2:
Practice Address - City:ELKVILLE
Practice Address - State:IL
Practice Address - Zip Code:62932-2220
Practice Address - Country:US
Practice Address - Phone:618-559-5035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490060171041C0700X
IL149-0060171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370966854004Medicaid
IL640701OtherPTAN
IL141816Medicare Oscar/Certification