MEDICARE: DR. SARAH VIDA PUCCIA PSY.D.

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
1	103T00000X	Psychologist	071.008339	IL

General Provider Information

NPI Number	:	1083952907
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SARAH VIDA PUCCIA PSY.D.

Provider Business Mailing Address
First Line	:	1324 W THORNDALE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-3306
Country	:	US
Telephone Number	:	773-852-7119
Fax Number	:	773-784-4035

Provider Business Practice Location Address
First Line	:	3601 N ASHLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-3660
Country	:	US
Telephone Number	:	872-222-9153
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/28/2013
Last Update Date	:	01/28/2013

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