Provider Demographics
NPI:1720334857
Name:BERGOUNOUS, PAULETTE MARIE (MS)
Entity type:Individual
Prefix:MS
First Name:PAULETTE
Middle Name:MARIE
Last Name:BERGOUNOUS
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 1:29313 N 128TH LN
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-5245
Mailing Address - Country:US
Mailing Address - Phone:916-203-3551
Mailing Address - Fax:623-225-7941
Practice Address - Street 1:29313 N. 128TH LN
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-2841
Practice Address - Country:US
Practice Address - Phone:916-203-3551
Practice Address - Fax:623-225-7941
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-26
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP7729235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist