Provider Demographics
NPI:1588344519
Name:VERGARA, VIVIANA (MS)
Entity type:Individual
Prefix:
First Name:VIVIANA
Middle Name:
Last Name:VERGARA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3652 W 70TH PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-4235
Mailing Address - Country:US
Mailing Address - Phone:773-574-4662
Mailing Address - Fax:
Practice Address - Street 1:421 HARRISON ST STE C
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60304-1461
Practice Address - Country:US
Practice Address - Phone:708-240-3874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242.007247235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist