Provider Demographics
NPI:1154820520
Name:BERGERON, KELLEY NOHEA
Entity type:Individual
Prefix:MISS
First Name:KELLEY
Middle Name:NOHEA
Last Name:BERGERON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94-494 FARRINGTON HWY APT 403
Mailing Address - Street 2:
Mailing Address - City:WAIPAHU
Mailing Address - State:HI
Mailing Address - Zip Code:96797-2638
Mailing Address - Country:US
Mailing Address - Phone:808-853-0674
Mailing Address - Fax:
Practice Address - Street 1:1253 S BERETANIA ST STE 2710
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-1822
Practice Address - Country:US
Practice Address - Phone:412-582-0296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-12
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRBT-18-47186106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician