Provider Demographics
NPI:1184124026
Name:BERGERON, SHEENA MARIE
Entity type:Individual
Prefix:
First Name:SHEENA
Middle Name:MARIE
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 1:552 E BARHAM DR APT 220
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-7401
Mailing Address - Country:US
Mailing Address - Phone:336-508-2711
Mailing Address - Fax:
Practice Address - Street 1:325 BUENA CREEK RD
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069-9679
Practice Address - Country:US
Practice Address - Phone:760-754-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-16
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101580101YM0800X
CA4285101YP2500X
CA126084106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional