Healthcare Provider Details

I. General information

NPI: 1356279814
Provider Name (Legal Business Name): STARGATE THERAPY INNOVATIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4025 N AUSTIN AVE
CHICAGO IL
60634-1605
US

IV. Provider business mailing address

4025 N AUSTIN AVE
CHICAGO IL
60634-1605
US

V. Phone/Fax

Practice location:
  • Phone: 773-372-5954
  • Fax: 773-372-5954
Mailing address:
  • Phone: 773-372-5954
  • Fax: 773-372-5954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN SULLIVAN
Title or Position: OWNER/MENTAL HEALTH THERAPIST
Credential: LCPC
Phone: 773-372-5954