Healthcare Provider Details

I. General information

NPI: 1073106977
Provider Name (Legal Business Name): BRANDON RUSSELL SILVERMAN LCPC, NCC, MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2021
Last Update Date: 09/27/2023
Certification Date: 09/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4049 N AUSTIN AVE
CHICAGO IL
60634-1605
US

IV. Provider business mailing address

4049 N AUSTIN AVE
CHICAGO IL
60634-1605
US

V. Phone/Fax

Practice location:
  • Phone: 312-286-5056
  • Fax:
Mailing address:
  • Phone: 312-286-5056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180013418
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: