Provider Demographics
NPI:1861481319
Name:BERGERON, LESLEY (MSPT)
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:
Last Name:BERGERON
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 MANOR PKWY
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SALEM
Mailing Address - State:NH
Mailing Address - Zip Code:03079-2841
Mailing Address - Country:US
Mailing Address - Phone:603-974-0817
Mailing Address - Fax:603-974-0863
Practice Address - Street 1:2 MANOR PKWY
Practice Address - Street 2:SUITE 3
Practice Address - City:SALEM
Practice Address - State:NH
Practice Address - Zip Code:03079-2841
Practice Address - Country:US
Practice Address - Phone:603-974-0817
Practice Address - Fax:603-974-0863
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16672225100000X
NH2880225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MADI Y69615Medicare ID - Type Unspecified