Provider Demographics
NPI:1043765035
Name:GORDON, BETH BERKOWITZ (MS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:BETH
Middle Name:BERKOWITZ
Last Name:GORDON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-3464
Mailing Address - Country:US
Mailing Address - Phone:914-329-4696
Mailing Address - Fax:
Practice Address - Street 1:215 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-3464
Practice Address - Country:US
Practice Address - Phone:914-329-4696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-18
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.012952235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist