Provider Demographics
NPI:1629126065
Name:BERNBOM, MADELINE PATRICIA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MADELINE
Middle Name:PATRICIA
Last Name:BERNBOM
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 OAKBROOK CTR
Mailing Address - Street 2:SUITE 720
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1806
Mailing Address - Country:US
Mailing Address - Phone:630-368-2700
Mailing Address - Fax:630-574-2772
Practice Address - Street 1:120 OAKBROOK CTR
Practice Address - Street 2:SUITE 720
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-1806
Practice Address - Country:US
Practice Address - Phone:630-368-2700
Practice Address - Fax:630-574-2772
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical