Provider Demographics
NPI:1598288870
Name:THULLEN, EDWIN JOSEPH (LCSW)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:JOSEPH
Last Name:THULLEN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3105 W 102ND ST
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-3516
Mailing Address - Country:US
Mailing Address - Phone:312-718-3495
Mailing Address - Fax:
Practice Address - Street 1:1938 E LINCOLN HWY UNIT 219
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-3860
Practice Address - Country:US
Practice Address - Phone:815-320-3749
Practice Address - Fax:815-320-3825
Is Sole Proprietor?:No
Enumeration Date:2017-07-19
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.018135101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health