Provider Demographics
NPI:1083274963
Name:BERGERON, ELIZABETH FREMIN (ST)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:FREMIN
Last Name:BERGERON
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 RENEE DR
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-3948
Mailing Address - Country:US
Mailing Address - Phone:985-665-3945
Mailing Address - Fax:
Practice Address - Street 1:1401 RENEE DR
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-3948
Practice Address - Country:US
Practice Address - Phone:985-665-3945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5568235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty