Healthcare Provider Details

I. General information

NPI: 1255662425
Provider Name (Legal Business Name): KENT W ANDERSON PHD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2010
Last Update Date: 01/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 W 465 N SUITE 130
PROVIDENCE UT
84332-8003
US

IV. Provider business mailing address

545 W 465 N SUITE 130
PROVIDENCE UT
84332-8003
US

V. Phone/Fax

Practice location:
  • Phone: 435-752-7627
  • Fax: 435-752-7802
Mailing address:
  • Phone: 435-752-7627
  • Fax: 435-752-7802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number324469-2501
License Number StateUT

VIII. Authorized Official

Name: DR. KENT W ANDERSON
Title or Position: PRESIDENT/OWNER
Credential: PHD
Phone: 435-752-7627