Provider Demographics
NPI:1700323540
Name:BERGERON, RICHARD II (PMHNP, MSN)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:BERGERON
Suffix:II
Gender:M
Credentials:PMHNP, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 WEBER ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:LA
Mailing Address - Zip Code:70538-4124
Mailing Address - Country:US
Mailing Address - Phone:337-828-2550
Mailing Address - Fax:337-355-2335
Practice Address - Street 1:1014 W TUNNEL BLVD
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-4050
Practice Address - Country:US
Practice Address - Phone:985-851-1717
Practice Address - Fax:985-851-7183
Is Sole Proprietor?:No
Enumeration Date:2017-01-31
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP09162363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2436546Medicaid
LA570122OtherMEDICARE