MEDICARE: MR. CRAIG W BERTHOLD L.C.S.W.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	120978-3501	UT

General Provider Information

NPI Number	:	1316088586
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CRAIG W BERTHOLD L.C.S.W.

Provider Business Mailing Address
First Line	:	415 MEDICAL DR
Second Line	:	SUITE C100
City	:	BOUNTIFUL
State	:	UT
Zip	:	84010-4946
Country	:	US
Telephone Number	:	801-292-2389
Fax Number	:	801-292-2873

Provider Business Practice Location Address
First Line	:	415 MEDICAL DR
Second Line	:	SUITE C100
City	:	BOUNTIFUL
State	:	UT
Zip	:	84010-4946
Country	:	US
Telephone Number	:	801-292-2389
Fax Number	:	801-292-2873

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/09/2007
Last Update Date	:	07/08/2007

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