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General NPI Number Information
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NPI Number | 1487361366
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Entity Type | Individual
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Provider Name | SIDRA KOSS LCP
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Gender | Female
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Dates
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Enumeration Date | 11/01/2022
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Last Update Date | 11/20/2023
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Provider Practice Location Address
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Address Line | 4201 N DAMEN AVE
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City | CHICAGO
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State | IL
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Zip | 60618-3021
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Country | US
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Telephone | 847-208-7873
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Fax |
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Provider Business Mailing Address
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Address Line | 2947 W BELDEN AVE UNIT 3
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City | CHICAGO
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State | IL
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Zip | 60647-2961
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Country | US
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Telephone | 502-544-0868
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 178.019598
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License Number State | IL
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