Provider Demographics
NPI:1285215244
Name:ANDERSON, SUSANNAH
Entity Type:Individual
Prefix:
First Name:SUSANNAH
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3577 S MILLBROOK CIR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-3888
Mailing Address - Country:US
Mailing Address - Phone:801-635-0310
Mailing Address - Fax:
Practice Address - Street 1:1108 W SOUTH JORDAN PKWY STE B
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-5505
Practice Address - Country:US
Practice Address - Phone:385-215-9084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health