Provider Demographics
NPI:1316088586
Name:BERTHOLD, CRAIG W (LCSW)
Entity type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:W
Last Name:BERTHOLD
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 MEDICAL DR
Mailing Address - Street 2:SUITE C100
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-4946
Mailing Address - Country:US
Mailing Address - Phone:801-292-2389
Mailing Address - Fax:801-292-2873
Practice Address - Street 1:415 MEDICAL DR
Practice Address - Street 2:SUITE C100
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4946
Practice Address - Country:US
Practice Address - Phone:801-292-2389
Practice Address - Fax:801-292-2873
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT120978-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical