Provider Demographics
NPI:1255662425
Name:KENT W ANDERSON PHD PC
Entity Type:Organization
Organization Name:KENT W ANDERSON PHD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENT
Authorized Official - Middle Name:W
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:435-752-7627
Mailing Address - Street 1:545 W 465 N
Mailing Address - Street 2:SUITE 130
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-8003
Mailing Address - Country:US
Mailing Address - Phone:435-752-7627
Mailing Address - Fax:435-752-7802
Practice Address - Street 1:545 W 465 N
Practice Address - Street 2:SUITE 130
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-8003
Practice Address - Country:US
Practice Address - Phone:435-752-7627
Practice Address - Fax:435-752-7802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-27
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT324469-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000074018Medicare PIN
S90860Medicare UPIN