=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730539925
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BERENICE G PEREZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2016
-----------------------------------------------------
Last Update Date | 06/17/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3109 PARK AVE
-----------------------------------------------------
City | BROOKFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60513-1321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-612-7288
-----------------------------------------------------
Fax | 708-255-2391
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3109 PARK AVE
-----------------------------------------------------
City | BROOKFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60513-1321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-612-7288
-----------------------------------------------------
Fax | 708-255-2391
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2355S0801X
-----------------------------------------------------
Taxonomy Name | Speech-Language Assistant
-----------------------------------------------------
License Number | 217000344
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------