=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336480144
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRENDAN D. SULLIVAN MSW, L.C.S.W
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2013
-----------------------------------------------------
Last Update Date | 03/05/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 711 DEVON AVE SUITE 203
-----------------------------------------------------
City | PARK RIDGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60068-4713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-650-7340
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1812 S FAIRVIEW AVE
-----------------------------------------------------
City | PARK RIDGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60068-1216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-650-7340
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149.015720
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------