MEDICARE: MR. WESLEY BERTAGNOLE

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	101YM0800X	Mental Health Counselor	13329991-6004	UT

General Provider Information

NPI Number	:	1477234656
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WESLEY BERTAGNOLE

Provider Business Mailing Address
First Line	:	7088 S PALO VERDE WAY APT 32
Second Line	:
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84121-6751
Country	:	US
Telephone Number	:	307-267-4049
Fax Number	:

Provider Business Practice Location Address
First Line	:	1930 S STATE ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84115-2311
Country	:	US
Telephone Number	:	307-267-4049
Fax Number	:

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

Provider Enumeration Date	:	07/31/2023
Last Update Date	:	07/31/2023

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Directions to “ MR. WESLEY BERTAGNOLE ” Practice Location

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