Healthcare Provider Details

I. General information

NPI: 1235896473
Provider Name (Legal Business Name): LAURA BERGERON DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA ANDERSON

II. Dates (important events)

Enumeration Date: 11/23/2021
Last Update Date: 11/23/2021
Certification Date: 11/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6801 HIGH GROVE BLVD
BURR RIDGE IL
60527-7585
US

IV. Provider business mailing address

1907 GREENSBORO DR
WHEATON IL
60189-8131
US

V. Phone/Fax

Practice location:
  • Phone: 630-920-2900
  • Fax:
Mailing address:
  • Phone: 847-452-9420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number070020207
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: