Provider Demographics
NPI:1477132470
Name:BERGERON, CALLIE JO (MS, BCBA)
Entity Type:Individual
Prefix:
First Name:CALLIE
Middle Name:JO
Last Name:BERGERON
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 NORTHLAND DR
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-4428
Mailing Address - Country:US
Mailing Address - Phone:920-851-8233
Mailing Address - Fax:
Practice Address - Street 1:1035 STRADER DR STE 150
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40505-4090
Practice Address - Country:US
Practice Address - Phone:859-899-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst