Provider Demographics
NPI:1457035925
Name:GORENBERG, BLAIR JACLYN (SLP)
Entity type:Individual
Prefix:
First Name:BLAIR
Middle Name:JACLYN
Last Name:GORENBERG
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3004 W TOUHY AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-2841
Mailing Address - Country:US
Mailing Address - Phone:216-408-2509
Mailing Address - Fax:
Practice Address - Street 1:3004 W TOUHY AVE APT 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-2841
Practice Address - Country:US
Practice Address - Phone:216-408-2509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.016702235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist