Provider Demographics
NPI:1568595106
Name:ANDERSON, TRACY BERT (LCSW)
Entity Type:Individual
Prefix:MR
First Name:TRACY
Middle Name:BERT
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5689 S REDWOOD RD # 30
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-5322
Mailing Address - Country:US
Mailing Address - Phone:801-359-4884
Mailing Address - Fax:801-532-1052
Practice Address - Street 1:5689 S REDWOOD RD # 30
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84123-5322
Practice Address - Country:US
Practice Address - Phone:801-359-4884
Practice Address - Fax:801-532-1052
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13493835011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical