Provider Demographics
NPI:1649587098
Name:PULLIAM, PATRICIA (LCSW, CAADC)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:
Last Name:PULLIAM
Suffix:
Gender:F
Credentials:LCSW, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 E 53RD ST
Mailing Address - Street 2:SUITE 606
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-4557
Mailing Address - Country:US
Mailing Address - Phone:773-642-4682
Mailing Address - Fax:
Practice Address - Street 1:1525 E 53RD ST
Practice Address - Street 2:SUITE 400
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-4557
Practice Address - Country:US
Practice Address - Phone:773-642-4682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-07
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL6603101YA0400X
IL149012421101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1649587098Medicaid