Provider Demographics
NPI:1093035834
Name:BERGERON, ALYSSA (OT)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:BERGERON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:LACONIA
Mailing Address - State:NH
Mailing Address - Zip Code:03246
Mailing Address - Country:US
Mailing Address - Phone:603-524-1741
Mailing Address - Fax:603-524-0262
Practice Address - Street 1:635 MAIN ST
Practice Address - Street 2:
Practice Address - City:LACONIA
Practice Address - State:NH
Practice Address - Zip Code:03246-3415
Practice Address - Country:US
Practice Address - Phone:603-524-1741
Practice Address - Fax:603-524-0262
Is Sole Proprietor?:No
Enumeration Date:2010-06-03
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH2001225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH2001OtherLICENSE NUMBER