Provider Demographics
NPI:1588209480
Name:BERGERON, BLANCHE NICOLE
Entity Type:Individual
Prefix:
First Name:BLANCHE
Middle Name:NICOLE
Last Name:BERGERON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BLANCHE
Other - Middle Name:NICOLE
Other - Last Name:ANDREWS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 52ND ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95819-2310
Mailing Address - Country:US
Mailing Address - Phone:916-712-4715
Mailing Address - Fax:
Practice Address - Street 1:9300 W STOCKTON BLVD
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-8070
Practice Address - Country:US
Practice Address - Phone:916-513-7960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-14
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105143106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist