Provider Demographics
NPI:1700298775
Name:BERGERON, MEGAN
Entity Type:Individual
Prefix:MISS
First Name:MEGAN
Middle Name:
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 1:144 PROGRESS ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:RI
Mailing Address - Zip Code:02865-3030
Mailing Address - Country:US
Mailing Address - Phone:401-465-7137
Mailing Address - Fax:
Practice Address - Street 1:528 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-5757
Practice Address - Country:US
Practice Address - Phone:401-276-4020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-27
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty