Provider Demographics
NPI:1215558648
Name:BERGESON, BETH
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:BERGESON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 N 1330 W STE A1
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-5116
Mailing Address - Country:US
Mailing Address - Phone:801-960-3040
Mailing Address - Fax:
Practice Address - Street 1:165 N 1330 W STE A1
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-5116
Practice Address - Country:US
Practice Address - Phone:801-960-3040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-27
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
UT13302874-3503104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No172V00000XOther Service ProvidersCommunity Health Worker