Provider Demographics
NPI:1710386222
Name:ANDERSEN, DEREK (LMFT)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:ANDERSEN
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5685 S 1475 E STE 2B
Mailing Address - Street 2:
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4598
Mailing Address - Country:US
Mailing Address - Phone:801-920-6352
Mailing Address - Fax:801-409-0905
Practice Address - Street 1:5685 S 1475 E STE 2B
Practice Address - Street 2:
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4598
Practice Address - Country:US
Practice Address - Phone:801-920-6352
Practice Address - Fax:801-409-0905
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-20
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT77744203902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist