Provider Demographics
NPI:1649606096
Name:BERGERON, CODY COOPER (LCSW)
Entity type:Individual
Prefix:MRS
First Name:CODY
Middle Name:COOPER
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 1:516 WOODRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-2577
Mailing Address - Country:US
Mailing Address - Phone:203-247-9039
Mailing Address - Fax:
Practice Address - Street 1:425 KINGS HWY E
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-4852
Practice Address - Country:US
Practice Address - Phone:203-307-0119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-17
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT89341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT8934OtherLICENSED CLINICAL SOCIAL WORKER