Provider Demographics
NPI:1932397809
Name:BERGERON, FAY ANN (RPT)
Entity Type:Individual
Prefix:
First Name:FAY
Middle Name:ANN
Last Name:BERGERON
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2208 DUMBARTON WAY
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33594-4117
Mailing Address - Country:US
Mailing Address - Phone:813-684-4520
Mailing Address - Fax:
Practice Address - Street 1:2530 RIDGETOP WAY
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33594
Practice Address - Country:US
Practice Address - Phone:813-684-9985
Practice Address - Fax:813-655-2622
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-04
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
FLPT13795225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist