Healthcare Provider Details

I. General information

NPI: 1518457712
Provider Name (Legal Business Name): ANSON FAMILY COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2018
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

1747 HERITAGE LN STE B101
SYRACUSE UT
84075-8546
US

V. Phone/Fax

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

VIII. Authorized Official

Name: MARC LEE ANSON
Title or Position: OWNER AND PROGRAM DIRECTOR
Credential: LCSW
Phone: 385-439-1926