Healthcare Provider Details

I. General information

NPI: 1689824112
Provider Name (Legal Business Name): DEBORAH BERGERON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2008
Last Update Date: 04/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2741 INDIAN SCHOOL RD NE
ALBUQUERQUE NM
87106-2653
US

IV. Provider business mailing address

2741 INDIAN SCHOOL RD NE
ALBUQUERQUE NM
87106-2653
US

V. Phone/Fax

Practice location:
  • Phone: 505-888-4774
  • Fax:
Mailing address:
  • Phone: 505-888-4774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1466
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: