Provider Demographics
NPI:1548870074
Name:BERGERON, TARA (LMSW)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:BERGERON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 MANSFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-2018
Mailing Address - Country:US
Mailing Address - Phone:860-450-7471
Mailing Address - Fax:
Practice Address - Street 1:40 MANSFIELD AVE
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-2018
Practice Address - Country:US
Practice Address - Phone:860-450-7471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-10
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT46921041C0700X
CT131611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical