Provider Demographics
NPI:1417660168
Name:O'SULLIVAN, MARY EILEEN (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:EILEEN
Last Name:O'SULLIVAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:EILEEN
Other - Last Name:O'SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:905 MANLEY RD
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-5561
Mailing Address - Country:US
Mailing Address - Phone:630-624-9620
Mailing Address - Fax:
Practice Address - Street 1:905 MANLEY RD
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-5561
Practice Address - Country:US
Practice Address - Phone:630-624-9620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-27
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0248001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical