Provider Demographics
NPI:1588442040
Name:BERGERON, GABRIELLE LELIA (MC/ MAAT)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:LELIA
Last Name:BERGERON
Suffix:
Gender:F
Credentials:MC/ MAAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2406 BLUEBONNET LN APT 207
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-4067
Mailing Address - Country:US
Mailing Address - Phone:713-715-9829
Mailing Address - Fax:
Practice Address - Street 1:11402 JOY ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-2752
Practice Address - Country:US
Practice Address - Phone:512-577-7483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX92903101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health