Provider Demographics
NPI:1437328622
Name:BERGERON, DIANE IRENE (OTR)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:IRENE
Last Name:BERGERON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78-6957 KAMEHAMEHA III RD
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-2528
Mailing Address - Country:US
Mailing Address - Phone:808-322-2790
Mailing Address - Fax:808-322-8813
Practice Address - Street 1:78-6957 KAMEHAMEHA III RD
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-2528
Practice Address - Country:US
Practice Address - Phone:808-322-2790
Practice Address - Fax:808-322-8813
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-21
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIOT-340225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist