Provider Demographics
NPI:1366888729
Name:BERGERON, LAETETIA CLAIRE (MOT, OTR/L)
Entity type:Individual
Prefix:
First Name:LAETETIA
Middle Name:CLAIRE
Last Name:BERGERON
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2092 GAITHER RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-4011
Mailing Address - Country:US
Mailing Address - Phone:301-738-9691
Mailing Address - Fax:
Practice Address - Street 1:9975 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3316
Practice Address - Country:US
Practice Address - Phone:301-738-9691
Practice Address - Fax:301-738-8897
Is Sole Proprietor?:No
Enumeration Date:2013-05-13
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD07106225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist