=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083952907
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARAH VIDA PUCCIA PSY.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2013
-----------------------------------------------------
Last Update Date | 01/28/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3601 N ASHLAND AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60613-3660
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 872-222-9153
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1324 W THORNDALE AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60660-3306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-852-7119
-----------------------------------------------------
Fax | 773-784-4035
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 071.008339
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------