Provider Demographics
NPI:1336480144
Name:SULLIVAN, BRENDAN D (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:BRENDAN
Middle Name:D
Last Name:SULLIVAN
Suffix:
Gender:M
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 1:1812 S FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1216
Mailing Address - Country:US
Mailing Address - Phone:847-650-7340
Mailing Address - Fax:
Practice Address - Street 1:711 DEVON AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-4713
Practice Address - Country:US
Practice Address - Phone:847-650-7340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-05
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0157201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical