Provider Demographics
NPI:1174253082
Name:SULKIN, REBECCA LYLE (LICSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYLE
Last Name:SULKIN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:BECKY
Other - Middle Name:
Other - Last Name:LYLE SULKIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:274 16TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-7174
Mailing Address - Country:US
Mailing Address - Phone:314-910-1703
Mailing Address - Fax:
Practice Address - Street 1:2525 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4518
Practice Address - Country:US
Practice Address - Phone:314-910-1703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN263981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical