Basic Information
| Provider Information | |||||||||
| NPI: | 1376850487 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERGEVIN | ||||||||
| FirstName: | RACHEL | ||||||||
| MiddleName: | DOROTHY | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | LICSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILLETTE | ||||||||
| OtherFirstName: | RACHEL | ||||||||
| OtherMiddleName: | DOROTHY | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LICSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 30 TAUNTON GRN | ||||||||
| Address2: | SUITE 5 | ||||||||
| City: | TAUNTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027803243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088806666 | ||||||||
| FaxNumber: | 5088806655 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 TAUNTON GRN | ||||||||
| Address2: | SUITE 5 | ||||||||
| City: | TAUNTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027803243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088806666 | ||||||||
| FaxNumber: | 5088806655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2010 | ||||||||
| LastUpdateDate: | 01/05/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.