Provider Demographics
NPI:1861907818
Name:BERGERON, KYLE
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:BERGERON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1253 S BERETANIA ST STE 2710
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-1822
Mailing Address - Country:US
Mailing Address - Phone:412-582-0296
Mailing Address - Fax:808-356-1310
Practice Address - Street 1:1253 S BERETANIA ST STE 2710
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-1822
Practice Address - Country:US
Practice Address - Phone:412-582-0296
Practice Address - Fax:808-356-1310
Is Sole Proprietor?:No
Enumeration Date:2017-12-12
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician