Basic Information
| Provider Information | |||||||||
| NPI: | 1821398330 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERESHNYI | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CSW | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 50 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | TOOELE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840742139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4358508723 | ||||||||
| FaxNumber: | 8017334083 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | TOOELE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840742139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4358508723 | ||||||||
| FaxNumber: | 8017334083 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2010 | ||||||||
| LastUpdateDate: | 10/31/2010 | ||||||||
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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 | 1041C0700X | 5216820-3502 | UT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.