Healthcare Provider Details

I. General information

NPI: 1770180549
Provider Name (Legal Business Name): SARA GOSIC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2020
Last Update Date: 10/05/2020
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15010 S RAVINIA AVE STE 15
ORLAND PARK IL
60462-5353
US

IV. Provider business mailing address

1323 BUTTERFIELD RD STE 116
DOWNERS GROVE IL
60515-5620
US

V. Phone/Fax

Practice location:
  • Phone: 708-364-0580
  • Fax:
Mailing address:
  • Phone: 708-364-0580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number1033410477
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: