Provider Demographics
NPI:1215769898
Name:BERGERON, BROOKE LAYNE
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:LAYNE
Last Name:BERGERON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:389 HIGHWAY 21 STE 403
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70447-3441
Mailing Address - Country:US
Mailing Address - Phone:985-792-5996
Mailing Address - Fax:
Practice Address - Street 1:389 HIGHWAY 21 STE 403
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:LA
Practice Address - Zip Code:70447-3441
Practice Address - Country:US
Practice Address - Phone:985-792-5996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-14
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11901225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist