Provider Demographics
NPI:1285910638
Name:BERGERON, TANISHA (MACCC-SLP)
Entity type:Individual
Prefix:
First Name:TANISHA
Middle Name:
Last Name:BERGERON
Suffix:
Gender:F
Credentials:MACCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:MOODUS
Mailing Address - State:CT
Mailing Address - Zip Code:06469-1168
Mailing Address - Country:US
Mailing Address - Phone:860-638-8612
Mailing Address - Fax:
Practice Address - Street 1:6 SCHOOL RD
Practice Address - Street 2:
Practice Address - City:MOODUS
Practice Address - State:CT
Practice Address - Zip Code:06469-1168
Practice Address - Country:US
Practice Address - Phone:860-638-8612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-31
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
CT005002235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist