Provider Demographics
NPI:1457719924
Name:BERGERON, PENELOPE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:PENELOPE
Middle Name:
Last Name:BERGERON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5612 W 10930 N
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:UT
Mailing Address - Zip Code:84003-8897
Mailing Address - Country:US
Mailing Address - Phone:801-318-7037
Mailing Address - Fax:
Practice Address - Street 1:315 S 100 E
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606-4649
Practice Address - Country:US
Practice Address - Phone:801-318-7037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-29
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7005879-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical