Provider Demographics
NPI:1861873705
Name:BERGSTROM, SUE
Entity type:Individual
Prefix:
First Name:SUE
Middle Name:
Last Name:BERGSTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 GRAND RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175-1074
Mailing Address - Country:US
Mailing Address - Phone:630-762-9984
Mailing Address - Fax:
Practice Address - Street 1:263 GRAND RIDGE RD
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60175-1074
Practice Address - Country:US
Practice Address - Phone:630-762-9984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-16
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.000404235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist