Provider Demographics
NPI:1124377635
Name:VIVODA, SARA PROBASCO (MOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:PROBASCO
Last Name:VIVODA
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:KAITLYN
Other - Last Name:PROBASCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOT, OTR/L
Mailing Address - Street 1:1757 N KIMBALL AVE STE 205A
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-4805
Mailing Address - Country:US
Mailing Address - Phone:816-914-0359
Mailing Address - Fax:
Practice Address - Street 1:1757 N KIMBALL AVE STE 205A
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-4805
Practice Address - Country:US
Practice Address - Phone:816-914-0359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.009836225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL93-3026418Medicaid