Provider Demographics
NPI:1164170023
Name:BERTHOLD, DOMINIK RYAN (MSW)
Entity Type:Individual
Prefix:MR
First Name:DOMINIK
Middle Name:RYAN
Last Name:BERTHOLD
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 N QUEEN ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17603-3878
Mailing Address - Country:US
Mailing Address - Phone:717-297-0515
Mailing Address - Fax:833-563-2325
Practice Address - Street 1:8 N QUEEN ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17603-3878
Practice Address - Country:US
Practice Address - Phone:717-297-0515
Practice Address - Fax:833-563-2325
Is Sole Proprietor?:No
Enumeration Date:2022-03-10
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program