Provider Demographics
NPI:1194097923
Name:BERGERON, LISA ADDIE (BCABA)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ADDIE
Last Name:BERGERON
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:ADDIE
Other - Last Name:PHELPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:163 LEDGEWOOD RD
Mailing Address - Street 2:UNIT 203
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-6611
Mailing Address - Country:US
Mailing Address - Phone:401-451-4863
Mailing Address - Fax:401-921-5493
Practice Address - Street 1:3445 POST RD
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-7147
Practice Address - Country:US
Practice Address - Phone:401-739-2700
Practice Address - Fax:401-921-5493
Is Sole Proprietor?:No
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI0-11-4097103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst