Provider Demographics
NPI:1932231974
Name:BERGERON, OLIVIA (LCSW)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:BERGERON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 80TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-3902
Mailing Address - Country:US
Mailing Address - Phone:917-747-7017
Mailing Address - Fax:
Practice Address - Street 1:451 80TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-3902
Practice Address - Country:US
Practice Address - Phone:917-747-7017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0780581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ44SC06094700OtherNJ LCSW LICENSE
FLTPSW1023OtherFLORIDA LICENSE NUMBER