Provider Demographics
NPI:1770390684
Name:ANDERSON, ELIZA MAVIS
Entity type:Individual
Prefix:
First Name:ELIZA
Middle Name:MAVIS
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELLIE
Other - Middle Name:
Other - Last Name:ANDERSON OWEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1460 E SHANE CIR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84092-5939
Mailing Address - Country:US
Mailing Address - Phone:801-906-9196
Mailing Address - Fax:
Practice Address - Street 1:1001 N 500 W
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3305
Practice Address - Country:US
Practice Address - Phone:801-377-9661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-13
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14195558-4003225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist