Provider Demographics
NPI:1194884460
Name:BERGERON, TONI R (LPC, CADC III, CDP)
Entity type:Individual
Prefix:MS
First Name:TONI
Middle Name:R
Last Name:BERGERON
Suffix:
Gender:F
Credentials:LPC, CADC III, CDP
Other - Prefix:MS
Other - First Name:TONI
Other - Middle Name:R
Other - Last Name:WAYMIRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:340 W CLARENDON ST
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:OR
Mailing Address - Zip Code:97027-2339
Mailing Address - Country:US
Mailing Address - Phone:503-841-8459
Mailing Address - Fax:503-657-2800
Practice Address - Street 1:1300 JOHN ADAMS ST
Practice Address - Street 2:SUITE 103
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1695
Practice Address - Country:US
Practice Address - Phone:503-841-8458
Practice Address - Fax:503-650-1970
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC2297101YP2500X
OR07-06-65101YA0400X
WACP00005704101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
1194884460OtherNATIONAL PROVIDER IDENTIFICATION NUMBER