Provider Demographics
NPI:1295496214
Name:SULLENBERG, MADELINE
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:SULLENBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 BURLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:CLARENDON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60514-1245
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:552 S WASHINGTON ST STE 115
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-6669
Practice Address - Country:US
Practice Address - Phone:312-924-6191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-02
Last Update Date:2022-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178017731101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL178017731OtherILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION