Healthcare Provider Details

I. General information

NPI: 1497244115
Provider Name (Legal Business Name): BRADY SULLIVAN LPC, NCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2018
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3115 S GRAND BLVD STE 300
SAINT LOUIS MO
63118-1046
US

IV. Provider business mailing address

4325 LOUGHBOROUGH AVE
SAINT LOUIS MO
63116-2103
US

V. Phone/Fax

Practice location:
  • Phone: 314-339-7356
  • Fax:
Mailing address:
  • Phone: 630-885-8663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number2018014894
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2018014894
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: