Provider Demographics
NPI:1104017920
Name:POULTON, BRYN ANNE (MSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:BRYN
Middle Name:ANNE
Last Name:POULTON
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 WESTGATE ST STE 205
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1022
Mailing Address - Country:US
Mailing Address - Phone:773-852-6898
Mailing Address - Fax:
Practice Address - Street 1:1103 WESTGATE ST STE 205
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1022
Practice Address - Country:US
Practice Address - Phone:773-852-6898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0098231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical