Provider Demographics
NPI:1063825974
Name:BERGERON, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:BERGERON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 CORLEY MILL RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-7600
Mailing Address - Country:US
Mailing Address - Phone:803-256-7041
Mailing Address - Fax:803-079-9462
Practice Address - Street 1:157 CORLEY MILL RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-7600
Practice Address - Country:US
Practice Address - Phone:803-256-7041
Practice Address - Fax:803-079-9462
Is Sole Proprietor?:No
Enumeration Date:2014-06-09
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4028231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4028OtherSTATE LICENSING