Healthcare Provider Details

I. General information

NPI: 1699548693
Provider Name (Legal Business Name): BERTHA BECERRA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2023
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5640 S PULASKI RD
CHICAGO IL
60629-4439
US

IV. Provider business mailing address

5502 SALMA ST
PLAINFIELD IL
60586-5682
US

V. Phone/Fax

Practice location:
  • Phone: 331-688-4342
  • Fax:
Mailing address:
  • Phone: 815-258-9893
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number23-284000
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: