Provider Demographics
NPI:1083952907
Name:PUCCIA, SARAH VIDA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SARAH
Middle Name:VIDA
Last Name:PUCCIA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1324 W THORNDALE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-3306
Mailing Address - Country:US
Mailing Address - Phone:773-852-7119
Mailing Address - Fax:773-784-4035
Practice Address - Street 1:3601 N ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-3660
Practice Address - Country:US
Practice Address - Phone:872-222-9153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-28
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.008339103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist