Provider Demographics
NPI:1114220159
Name:BERGERON, REBECCA (MSW, LGSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:BERGERON
Suffix:
Gender:F
Credentials:MSW, LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 SEVERN ST
Mailing Address - Street 2:#1
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-1740
Mailing Address - Country:US
Mailing Address - Phone:410-752-5525
Mailing Address - Fax:
Practice Address - Street 1:1001 W SARATOGA ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21223-1915
Practice Address - Country:US
Practice Address - Phone:410-396-1290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-14
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD14999101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health