Provider Demographics
NPI:1982238580
Name:BERGERON, CHRISTINE R (LCSW)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:R
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:PO BOX 568
Mailing Address - Street 2:
Mailing Address - City:KENNEBUNKPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04046-0568
Mailing Address - Country:US
Mailing Address - Phone:603-689-6562
Mailing Address - Fax:
Practice Address - Street 1:53 BAXTER BLVD STE 3
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-1827
Practice Address - Country:US
Practice Address - Phone:603-689-6562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-24
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC231621041C0700X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical