Healthcare Provider Details

I. General information

NPI: 1891631180
Provider Name (Legal Business Name): BERNADETA MROWCA GANGESTAD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2026
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9319 S 84TH AVE
HICKORY HILLS IL
60457-1805
US

IV. Provider business mailing address

9319 S 84TH AVE
HICKORY HILLS IL
60457-1805
US

V. Phone/Fax

Practice location:
  • Phone: 708-539-6699
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.023075
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: