MEDICARE: MRS. GRETCHEN ANN BERGEN M.A., SLP/L

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	235Z00000X	Speech-Language Pathologist	146.00632	IL

General Provider Information

NPI Number	:	1316908619
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GRETCHEN ANN BERGEN M.A., SLP/L

Provider Business Mailing Address
First Line	:	1212 MINK TRL
Second Line	:
City	:	CARY
State	:	IL
Zip	:	60013-6066
Country	:	US
Telephone Number	:	847-639-7963
Fax Number	:	847-639-1506

Provider Business Practice Location Address
First Line	:	1212 MINK TRL
Second Line	:
City	:	CARY
State	:	IL
Zip	:	60013-6066
Country	:	US
Telephone Number	:	847-639-7963
Fax Number	:	847-639-1506

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

Provider Enumeration Date	:	03/28/2006
Last Update Date	:	07/08/2007

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