Provider Demographics
NPI:1134653025
Name:BERCEGEAY, LISA (BA, LMT, CST-P)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BERCEGEAY
Suffix:
Gender:F
Credentials:BA, LMT, CST-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45016 GOLD PLACE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT AMANT
Mailing Address - State:LA
Mailing Address - Zip Code:70774-3619
Mailing Address - Country:US
Mailing Address - Phone:225-571-2943
Mailing Address - Fax:
Practice Address - Street 1:45016 GOLD PLACE RD
Practice Address - Street 2:
Practice Address - City:SAINT AMANT
Practice Address - State:LA
Practice Address - Zip Code:70774-3619
Practice Address - Country:US
Practice Address - Phone:225-571-2943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA5459171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor