Healthcare Provider Details

I. General information

NPI: 1649190919
Provider Name (Legal Business Name): GRACE BERGERON
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2026
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 SOUND RD STE 200
HOLLY RIDGE NC
28445-7813
US

IV. Provider business mailing address

315 BEAUMONT OAKS DR
WILMINGTON NC
28411-0315
US

V. Phone/Fax

Practice location:
  • Phone: 910-541-3636
  • Fax:
Mailing address:
  • Phone: 315-360-8738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: