Provider Demographics
NPI:1659553261
Name:BERGERON, CARLA
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:BERGERON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 MIDDLESEX ST APT 1
Mailing Address - Street 2:
Mailing Address - City:NORTH CHELMSFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01863-1571
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:126 PHOENIX AVE BLDG 2
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-4931
Practice Address - Country:US
Practice Address - Phone:978-453-8331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-05
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS41308265222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist