Provider Demographics
NPI:1477566065
Name:BERGERON, KATHRYN A (LCMHC)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:A
Last Name:BERGERON
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 84
Mailing Address - Street 2:
Mailing Address - City:BARNET
Mailing Address - State:VT
Mailing Address - Zip Code:05821-0084
Mailing Address - Country:US
Mailing Address - Phone:802-633-3632
Mailing Address - Fax:
Practice Address - Street 1:2688 ROY MOUNTAIN ROAD
Practice Address - Street 2:
Practice Address - City:BARNET
Practice Address - State:VT
Practice Address - Zip Code:05821
Practice Address - Country:US
Practice Address - Phone:802-633-3632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT068-0000541101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTIP562608OtherMAGELLON
VT080-58463OtherBLUE CROSS BLUE SHIELD
VT21219232904OtherBEECH STREET
VT610252OtherMVP HEALTH PLAN
VT1008471Medicaid
VT2086238OtherCIGNA