Provider Demographics
NPI:1861043317
Name:MOGK, BREANNA (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:BREANNA
Middle Name:
Last Name:MOGK
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 1:2160 DURFEE RD
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60189-7812
Mailing Address - Country:US
Mailing Address - Phone:630-682-2190
Mailing Address - Fax:
Practice Address - Street 1:2160 DURFEE RD
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60189-7812
Practice Address - Country:US
Practice Address - Phone:630-682-2190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-26
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146013355235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist