Provider Demographics
NPI:1316908619
Name:BERGEN, GRETCHEN ANN (MA, SLP/L)
Entity type:Individual
Prefix:MRS
First Name:GRETCHEN
Middle Name:ANN
Last Name:BERGEN
Suffix:
Gender:F
Credentials:MA, SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 MINK TRL
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:IL
Mailing Address - Zip Code:60013-6066
Mailing Address - Country:US
Mailing Address - Phone:847-639-7963
Mailing Address - Fax:847-639-1506
Practice Address - Street 1:1212 MINK TRL
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:IL
Practice Address - Zip Code:60013-6066
Practice Address - Country:US
Practice Address - Phone:847-639-7963
Practice Address - Fax:847-639-1506
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.00632235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist