Provider Demographics
NPI:1245793066
Name:LOREDO, SARA VICENTE (LCPC)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:VICENTE
Last Name:LOREDO
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12145 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406-1387
Mailing Address - Country:US
Mailing Address - Phone:773-573-3857
Mailing Address - Fax:
Practice Address - Street 1:12145 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-1387
Practice Address - Country:US
Practice Address - Phone:773-537-3857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180011508101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional