Provider Demographics
NPI:1629369103
Name:CHIDESTER, ANITA M (STUDENT INTERN)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:M
Last Name:CHIDESTER
Suffix:
Gender:F
Credentials:STUDENT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-2725
Mailing Address - Country:US
Mailing Address - Phone:801-359-8862
Mailing Address - Fax:207-359-8510
Practice Address - Street 1:411 GRANT ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84116-2725
Practice Address - Country:US
Practice Address - Phone:801-359-8862
Practice Address - Fax:207-359-8510
Is Sole Proprietor?:No
Enumeration Date:2011-05-02
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)