Provider Demographics
NPI:1245793249
Name:ANDERSON WELLNESS GROUP LLC
Entity Type:Organization
Organization Name:ANDERSON WELLNESS GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APRN
Authorized Official - Prefix:DR
Authorized Official - First Name:SUMER
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:801-676-9452
Mailing Address - Street 1:9533 S 700 E STE 203
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-3456
Mailing Address - Country:US
Mailing Address - Phone:801-792-1034
Mailing Address - Fax:
Practice Address - Street 1:9533 S 700 E STE 203
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-3456
Practice Address - Country:US
Practice Address - Phone:801-792-1034
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-08
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1992071559Medicaid