Provider Demographics
NPI:1447820824
Name:DAVIS, SARAH D (EDM)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:D
Last Name:DAVIS
Suffix:
Gender:F
Credentials:EDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1544 W GLENLAKE AVE APT 5A
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-1872
Mailing Address - Country:US
Mailing Address - Phone:773-816-7624
Mailing Address - Fax:
Practice Address - Street 1:719 N MARION ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-1530
Practice Address - Country:US
Practice Address - Phone:844-478-6878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD120-7849-7928OtherDRIVERS LICENSE