Provider Demographics
NPI:1578968954
Name:BERTAGNOLLI, SHAYDEN JAMES (MS LMFT)
Entity Type:Individual
Prefix:
First Name:SHAYDEN
Middle Name:JAMES
Last Name:BERTAGNOLLI
Suffix:
Gender:M
Credentials:MS LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5685 S 1475 E STE 2B
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4598
Mailing Address - Country:US
Mailing Address - Phone:435-315-2520
Mailing Address - Fax:
Practice Address - Street 1:5685 S 1475 E STE 2B
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4598
Practice Address - Country:US
Practice Address - Phone:435-315-2520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-28
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9109494-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist