MEDICARE: SARA PROBASCO VIVODA MOT, OTR/L, CLC

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	225XF0002X	Feeding, Eating & Swallowing Occupational Therapist	056.009836	IL
2	225X00000X	Occupational Therapist	056.009836	IL
3	174N00000X	Lactation Consultant (Non-RN)		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	93-3026418	OTHER	IL	CLEMENTINEPEDIATRICS

General Provider Information

NPI Number	:	1124377635
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARA PROBASCO VIVODA MOT, OTR/L, CLC

Provider Business Mailing Address
First Line	:	1757 N KIMBALL AVE STE 205A
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-4805
Country	:	US
Telephone Number	:	816-914-0359
Fax Number	:

Provider Business Practice Location Address
First Line	:	1757 N KIMBALL AVE STE 205A
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-4805
Country	:	US
Telephone Number	:	816-914-0359
Fax Number	:

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

Provider Enumeration Date	:	08/30/2012
Last Update Date	:	10/01/2025

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