Provider Demographics
NPI:1629104872
Name:BERGERON, CLARENCE (PHD PSYCHOLOGY)
Entity Type:Individual
Prefix:DR
First Name:CLARENCE
Middle Name:
Last Name:BERGERON
Suffix:
Gender:M
Credentials:PHD PSYCHOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 BELANGER ST
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-4437
Mailing Address - Country:US
Mailing Address - Phone:985-851-6257
Mailing Address - Fax:985-851-6065
Practice Address - Street 1:625 BELANGER ST
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-4437
Practice Address - Country:US
Practice Address - Phone:985-851-6257
Practice Address - Fax:985-851-6065
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA455103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist