Healthcare Provider Details

I. General information

NPI: 1700250453
Provider Name (Legal Business Name): VANCE ANDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2015
Last Update Date: 11/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

269 W 3300 S
OGDEN UT
84401-3845
US

IV. Provider business mailing address

4763 BRINKER AVE
OGDEN UT
84403-4242
US

V. Phone/Fax

Practice location:
  • Phone: 801-393-2742
  • Fax: 801-393-2184
Mailing address:
  • Phone: 801-979-3462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number261721-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: