Provider Demographics
NPI:1477841823
Name:BERGERON, DEREK (PHD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:BERGERON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 COCHRANE CIR
Mailing Address - Street 2:EVANS ARMY COMMUNITY HOSPITAL
Mailing Address - City:FORT CARSON
Mailing Address - State:CO
Mailing Address - Zip Code:80913
Mailing Address - Country:US
Mailing Address - Phone:719-524-3508
Mailing Address - Fax:
Practice Address - Street 1:1650 COCHRANE CIR
Practice Address - Street 2:EVANS ARMY COMMUNITY HOSPITAL
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913
Practice Address - Country:US
Practice Address - Phone:719-503-7920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY.0004175103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2865917Medicaid
TX2865917Medicaid