1700295458 NPI number — CAMERON BERGERON LICSW

Table of content: CAMERON BERGERON LICSW (NPI 1700295458)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700295458 NPI number — CAMERON BERGERON LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERGERON
Provider First Name:
CAMERON
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HOLMES
Provider Other First Name:
CAMERON
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1700295458
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/25/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
77 NORTHEASTERN BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NASHUA
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03062-3128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-882-3616
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
45 HIGH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NASHUA
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03060-3312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-816-3133
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/07/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)