Provider Demographics
NPI:1598174385
Name:ANDERSON, PARKER KEONI (ASUDC)
Entity Type:Individual
Prefix:
First Name:PARKER
Middle Name:KEONI
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:ASUDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1904 W GORDON AVE
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-7232
Mailing Address - Country:US
Mailing Address - Phone:801-444-0794
Mailing Address - Fax:
Practice Address - Street 1:1904 W GORDON AVE
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-7232
Practice Address - Country:US
Practice Address - Phone:801-444-0794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5894886-6006101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)