Provider Demographics
NPI:1235886524
Name:SULLIVAN, BYRON JOHN (LSW)
Entity Type:Individual
Prefix:
First Name:BYRON
Middle Name:JOHN
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7324 N RIDGE BLVD APT 2W
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-2052
Mailing Address - Country:US
Mailing Address - Phone:301-710-3624
Mailing Address - Fax:
Practice Address - Street 1:700 N GREEN ST STE 103
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-5996
Practice Address - Country:US
Practice Address - Phone:312-620-8836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-07
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.105486104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty