Provider Demographics
NPI:1497244115
Name:SULLIVAN, BRADY (LPC, NCC)
Entity Type:Individual
Prefix:DR
First Name:BRADY
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4325 LOUGHBOROUGH AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-2103
Mailing Address - Country:US
Mailing Address - Phone:630-885-8663
Mailing Address - Fax:
Practice Address - Street 1:3115 S GRAND BLVD STE 300
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63118-1046
Practice Address - Country:US
Practice Address - Phone:314-339-7356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-08
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018014894101YM0800X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty