Healthcare Provider Details

I. General information

NPI: 1356328272
Provider Name (Legal Business Name): C. LEROY ANDERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: CLARENCE LEROY ANDERSON M.D.

II. Dates (important events)

Enumeration Date: 12/30/2005
Last Update Date: 06/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 N 500 W UTAH VALLEY PSYCHIATRY AND COUNSELING CLINIC
PROVO UT
84604-3380
US

IV. Provider business mailing address

1034 N 500 W UTAH VALLEY PSYCHIATRY AND COUNSELING CLINIC
PROVO UT
84604-3380
US

V. Phone/Fax

Practice location:
  • Phone: 801-357-7525
  • Fax:
Mailing address:
  • Phone: 801-357-7525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number821686511205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number821686511205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: