Basic Information
| Provider Information | |||||||||
| NPI: | 1033767629 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERTOCH | ||||||||
| FirstName: | LONDON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2096 W. COMMANCHE RD. | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9288307133 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1561 W 7000 S STE 200 | ||||||||
| Address2: | |||||||||
| City: | WEST JORDAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840843556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019904300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2019 | ||||||||
| LastUpdateDate: | 08/28/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 11413713-6009 | UT | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.