Provider Demographics
NPI:1225800493
Name:PROVIS, SARA E (LPC)
Entity Type:Individual
Prefix:MRS
First Name:SARA
Middle Name:E
Last Name:PROVIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1422 LAVERNE AVE
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-2561
Mailing Address - Country:US
Mailing Address - Phone:847-529-8607
Mailing Address - Fax:
Practice Address - Street 1:1422 LAVERNE AVE
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-2561
Practice Address - Country:US
Practice Address - Phone:847-529-8607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.019455101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional