Provider Demographics
NPI:1841583234
Name:ANDERSON, BETHANY LAURAL (LCSW, RPT)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:LAURAL
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LCSW, RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 E 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103-2975
Mailing Address - Country:US
Mailing Address - Phone:602-550-4686
Mailing Address - Fax:
Practice Address - Street 1:1576 S 500 W STE 202
Practice Address - Street 2:
Practice Address - City:WOODS CROSS
Practice Address - State:UT
Practice Address - Zip Code:84010-7433
Practice Address - Country:US
Practice Address - Phone:801-406-9002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-18
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
UT8281717-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)