Provider Demographics
NPI:1487361366
Name:KOSS, SIDRA (LCP)
Entity type:Individual
Prefix:MRS
First Name:SIDRA
Middle Name:
Last Name:KOSS
Suffix:
Gender:F
Credentials:LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2947 W BELDEN AVE UNIT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-2961
Mailing Address - Country:US
Mailing Address - Phone:502-544-0868
Mailing Address - Fax:
Practice Address - Street 1:4201 N DAMEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-3021
Practice Address - Country:US
Practice Address - Phone:847-208-7873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-01
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.019598101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health