Provider Demographics
NPI:1356328272
Name:ANDERSON, C. LEROY (MD)
Entity Type:Individual
Prefix:DR
First Name:C.
Middle Name:LEROY
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:CLARENCE
Other - Middle Name:LEROY
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1034 N 500 W
Mailing Address - Street 2:UTAH VALLEY PSYCHIATRY AND COUNSELING CLINIC
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3380
Mailing Address - Country:US
Mailing Address - Phone:801-357-7525
Mailing Address - Fax:
Practice Address - Street 1:1034 N 500 W
Practice Address - Street 2:UTAH VALLEY PSYCHIATRY AND COUNSELING CLINIC
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3380
Practice Address - Country:US
Practice Address - Phone:801-357-7525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-30
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8216865112052084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD26525Medicare UPIN
UT000062580Medicare PIN
UT005763502Medicare ID - Type Unspecified