Healthcare Provider Details

I. General information

NPI: 1124377635
Provider Name (Legal Business Name): SARA PROBASCO VIVODA MOT, OTR/L, CLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SARA KAITLYN PROBASCO MOT, OTR/L, CLC

II. Dates (important events)

Enumeration Date: 08/30/2012
Last Update Date: 10/01/2025
Certification Date: 10/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1757 N KIMBALL AVE STE 205A
CHICAGO IL
60647-4805
US

IV. Provider business mailing address

1757 N KIMBALL AVE STE 205A
CHICAGO IL
60647-4805
US

V. Phone/Fax

Practice location:
  • Phone: 816-914-0359
  • Fax:
Mailing address:
  • Phone: 816-914-0359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapist
License Number056.009836
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056.009836
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: