Provider Demographics
NPI:1982423711
Name:SULLIVAN, MIRANDA BRICKNER (LPC)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:BRICKNER
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:JEAN
Other - Last Name:BRICKNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2239 N SPAULDING AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-2711
Mailing Address - Country:US
Mailing Address - Phone:715-571-7469
Mailing Address - Fax:
Practice Address - Street 1:1748 N KIMBALL AVE STE 206
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-4806
Practice Address - Country:US
Practice Address - Phone:872-588-1071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-08
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional