Provider Demographics
NPI:1740568385
Name:SULLIVAN, MIRIAM LIZETTE (MA, LCPC)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:LIZETTE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6848 W 114TH PL
Mailing Address - Street 2:
Mailing Address - City:WORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60482-2015
Mailing Address - Country:US
Mailing Address - Phone:708-691-2497
Mailing Address - Fax:
Practice Address - Street 1:10725 S WESTERN AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-3135
Practice Address - Country:US
Practice Address - Phone:708-691-2497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-01
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.007775101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional