Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251G0304X | Physical Therapist - Geriatrics | 070020207 | IL |
NPI | 1235896473 |
---|---|
Provider Name | Laura Bergeron |
First Address | Wheaton, IL 60189-8131 |
Second Address | Burr Ridge, IL 60527-7585 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/11/2021 |
Last Update Date | 23/11/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
070020207 | IL DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION (01) | IL |