Provider Demographics
NPI:1578770418
Name:BERGET, SHEMAINE LYNISE (OTR)
Entity Type:Individual
Prefix:
First Name:SHEMAINE
Middle Name:LYNISE
Last Name:BERGET
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:SHEMAINE
Other - Middle Name:LYNISE
Other - Last Name:BULLARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:715 E DIXIE AVE
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-5926
Mailing Address - Country:US
Mailing Address - Phone:352-728-3020
Mailing Address - Fax:
Practice Address - Street 1:715 E DIXIE AVE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5926
Practice Address - Country:US
Practice Address - Phone:352-728-3020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.008750225X00000X
MI5201005840225X00000X
IN31000917A225X00000X
AZ5157225X00000X
FL17586225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist