Healthcare Provider Details

I. General information

NPI: 1144486895
Provider Name (Legal Business Name): MARC LEE ANSON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2008
Last Update Date: 12/19/2019
Certification Date: 12/19/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1747 HERITAGE LN STE B101
SYRACUSE UT
84075-8546
US

IV. Provider business mailing address

1141 W 3090 S
SYRACUSE UT
84075-9083
US

V. Phone/Fax

Practice location:
  • Phone: 385-439-1926
  • Fax:
Mailing address:
  • Phone: 801-791-2073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5780998-3501
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier876000308007
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: