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NPI Code Detail

MEDICARE: DR. BRADY SULLIVAN LPC, NCC

MEDICARE: DR. BRADY SULLIVAN LPC, NCC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YM0800XMental Health Counselor2018014894MO
2101Y00000XCounselor2018014894MO

General Provider Information

NPI Number : 1497244115
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. BRADY SULLIVAN LPC, NCC
Provider Business Mailing Address
First Line : 4325 LOUGHBOROUGH AVE
Second Line :
City : SAINT LOUIS
State : MO
Zip : 63116-2103
Country : US
Telephone Number : 630-885-8663
Fax Number :
Provider Business Practice Location Address
First Line : 3115 S GRAND BLVD STE 300
Second Line :
City : SAINT LOUIS
State : MO
Zip : 63118-1046
Country : US
Telephone Number : 314-339-7356
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/08/2018
Last Update Date : 05/04/2022

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