MEDICARE: CARRIE BERGEN

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	1041C0700X	Clinical Social Worker	149.013423	IL

General Provider Information

NPI Number	:	1235567439
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARRIE BERGEN

Provider Business Mailing Address
First Line	:	4980 N. MARINE DRIVE
Second Line	:	UNIT 831
City	:	CHICAGO
State	:	IL
Zip	:	60640
Country	:	US
Telephone Number	:	312-730-7733
Fax Number	:

Provider Business Practice Location Address
First Line	:	4980 N MARINE DR
Second Line	:	UNIT 831
City	:	CHICAGO
State	:	IL
Zip	:	60640-3969
Country	:	US
Telephone Number	:	312-730-7733
Fax Number	:

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

Provider Enumeration Date	:	10/24/2013
Last Update Date	:	10/24/2013

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Directions to “ CARRIE BERGEN ” Practice Location

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