Provider Demographics
NPI:1215588900
Name:BERTHOLD, CLYDE KEITH III
Entity Type:Individual
Prefix:MR
First Name:CLYDE
Middle Name:KEITH
Last Name:BERTHOLD
Suffix:III
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:TY
Other - Middle Name:KEITH
Other - Last Name:BERTHOLD
Other - Suffix:III
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:21600 OXNARD ST STE 1800
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-7807
Mailing Address - Country:US
Mailing Address - Phone:818-345-2345
Mailing Address - Fax:
Practice Address - Street 1:5801 NE CORNELIUS PASS RD
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-9370
Practice Address - Country:US
Practice Address - Phone:971-762-1144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORA710535103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst