Provider Demographics
NPI:1164161394
Name:VICKERY, SARA (MS, CF-SLP)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:VICKERY
Suffix:
Gender:F
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12244 S SPENCER ST APT 3N
Mailing Address - Street 2:
Mailing Address - City:ALSIP
Mailing Address - State:IL
Mailing Address - Zip Code:60803-2536
Mailing Address - Country:US
Mailing Address - Phone:708-506-1164
Mailing Address - Fax:
Practice Address - Street 1:4560 W 103RD ST STE 2
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-4870
Practice Address - Country:US
Practice Address - Phone:708-581-5798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-04
Last Update Date:2022-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242.006476235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL242.006476OtherSTATE OF IL