Provider Demographics
NPI:1821699919
Name:HEIDBREDER, SARA OGAWA (LCPC, BC-DMT)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:OGAWA
Last Name:HEIDBREDER
Suffix:
Gender:F
Credentials:LCPC, BC-DMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4028 W IRVING PARK RD # LOFTB
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-2925
Mailing Address - Country:US
Mailing Address - Phone:773-850-9046
Mailing Address - Fax:
Practice Address - Street 1:4028 W IRVING PARK RD # LOFTB
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-2925
Practice Address - Country:US
Practice Address - Phone:773-850-9046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.012154101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional