Healthcare Provider Details

I. General information

NPI: 1023415775
Provider Name (Legal Business Name): SARA FIDLOW LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SARA CHLEBANOWSKI

II. Dates (important events)

Enumeration Date: 11/24/2014
Last Update Date: 12/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 MARTIN LUTHER KING DR
BLOOMINGTON IL
61701-1429
US

IV. Provider business mailing address

502 S MORRIS AVE
BLOOMINGTON IL
61701-4884
US

V. Phone/Fax

Practice location:
  • Phone: 309-827-6026
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number140.017099
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.017099
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: