Provider Demographics
NPI:1134562903
Name:ANDERSON, MARK WILLIAM (MS, MFT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:WILLIAM
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MS, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 573
Mailing Address - Street 2:
Mailing Address - City:ESCALANTE
Mailing Address - State:UT
Mailing Address - Zip Code:84726-0573
Mailing Address - Country:US
Mailing Address - Phone:702-722-9870
Mailing Address - Fax:
Practice Address - Street 1:500 S. 580 W.
Practice Address - Street 2:
Practice Address - City:ESCALANTE
Practice Address - State:UT
Practice Address - Zip Code:84726
Practice Address - Country:US
Practice Address - Phone:702-541-0061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-11
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7472928-3902106H00000X
NV01235106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist