Provider Demographics
NPI:1497454441
Name:BERGERON, BRIDGETTE MARGUERITE (LMT)
Entity Type:Individual
Prefix:
First Name:BRIDGETTE
Middle Name:MARGUERITE
Last Name:BERGERON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:BRIDGETTE
Other - Middle Name:MARGUERITE
Other - Last Name:HORAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:1300 LONESOME DOVE TRL
Mailing Address - Street 2:
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-7977
Mailing Address - Country:US
Mailing Address - Phone:469-777-0358
Mailing Address - Fax:
Practice Address - Street 1:5509 PLEASANT VALLEY DR STE 50
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75023-5225
Practice Address - Country:US
Practice Address - Phone:469-443-6025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-28
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX116488225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX116488OtherLMT