MEDICARE: EMILY BERGKOETTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	056.014091	IL

General Provider Information

NPI Number	:	1205532298
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMILY BERGKOETTER

Provider Business Mailing Address
First Line	:	3111 N CLIFTON AVE APT 2F
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-3371
Country	:	US
Telephone Number	:	618-975-9322
Fax Number	:

Provider Business Practice Location Address
First Line	:	2833 N NORDICA AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-4726
Country	:	US
Telephone Number	:	773-622-6144
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/01/2023
Last Update Date	:	02/01/2023

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