MEDICARE: DR. SARA PATTERSON LACASSE PH.D.

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	103TC0700X	Clinical Psychologist	071009189	IL

General Provider Information

NPI Number	:	1801120647
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SARA PATTERSON LACASSE PH.D.

Provider Business Mailing Address
First Line	:	5100 N RAVENSWOOD AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-1710
Country	:	US
Telephone Number	:	617-429-6129
Fax Number	:

Provider Business Practice Location Address
First Line	:	5100 N RAVENSWOOD AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-1710
Country	:	US
Telephone Number	:	617-429-6129
Fax Number	:

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

Provider Enumeration Date	:	09/27/2009
Last Update Date	:	12/09/2015

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