=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255662425
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KENT W ANDERSON PHD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2010
-----------------------------------------------------
Last Update Date | 01/27/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 545 W 465 N SUITE 130
-----------------------------------------------------
City | PROVIDENCE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84332-8003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-752-7627
-----------------------------------------------------
Fax | 435-752-7802
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 545 W 465 N SUITE 130
-----------------------------------------------------
City | PROVIDENCE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84332-8003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-752-7627
-----------------------------------------------------
Fax | 435-752-7802
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | DR. KENT W ANDERSON
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 435-752-7627
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 324469-2501
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------