MEDICARE: MISS SARA VIVENS LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	178.011447	IL

General Provider Information

NPI Number	:	1245773845
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS SARA VIVENS LPC

Provider Business Mailing Address
First Line	:	5205 N WAYNE AVE
Second Line	:	APT 2M
City	:	CHICAGO
State	:	IL
Zip	:	60640-2242
Country	:	US
Telephone Number	:	614-439-8983
Fax Number	:

Provider Business Practice Location Address
First Line	:	5205 N WAYNE AVE
Second Line	:	APT 2M
City	:	CHICAGO
State	:	IL
Zip	:	60640-2242
Country	:	US
Telephone Number	:	614-439-8983
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2016
Last Update Date	:	11/30/2016

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