Healthcare Provider Details

I. General information

NPI: 1447507801
Provider Name (Legal Business Name): MICHAEL CHARLES BARTLETT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2012
Last Update Date: 06/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 E CENTER ST
PROVO UT
84606-3554
US

IV. Provider business mailing address

PO BOX 270
PROVO UT
84603-0270
US

V. Phone/Fax

Practice location:
  • Phone: 801-344-4400
  • Fax:
Mailing address:
  • Phone: 801-344-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8569803-3501
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: