Basic Information
| Provider Information | |||||||||
| NPI: | 1124513429 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERGERON | ||||||||
| FirstName: | ARIEL | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 650 JOEL DR | ||||||||
| Address2: | |||||||||
| City: | FORT CAMPBELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422235318 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 650 JOEL DR | ||||||||
| Address2: | |||||||||
| City: | FORT CAMPBELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422235318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707988400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2018 | ||||||||
| LastUpdateDate: | 10/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | P012686 | NC | N | Behavioral Health & Social Service Providers | Social Worker | 390200000X | 65937 | TX | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 1041C0700X | C013209 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 65937 | 01 | TX | FEDERAL-MILITARY | OTHER |