Provider Demographics
NPI:1881895787
Name:GATES, BERNADETTE ANN (OTR)
Entity type:Individual
Prefix:MS
First Name:BERNADETTE
Middle Name:ANN
Last Name:GATES
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 MCHENRY AVE
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-7147
Mailing Address - Country:US
Mailing Address - Phone:815-260-0131
Mailing Address - Fax:
Practice Address - Street 1:5150 NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-8058
Practice Address - Country:US
Practice Address - Phone:847-842-4167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.006590282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital