Provider Demographics
NPI:1932231016
Name:ANDERSON, KENT W (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENT
Middle Name:W
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 W 465 N
Mailing Address - Street 2:SUITE 130
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-8003
Mailing Address - Country:US
Mailing Address - Phone:435-752-7627
Mailing Address - Fax:435-752-7802
Practice Address - Street 1:545 W 465 N
Practice Address - Street 2:SUITE 130
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-8003
Practice Address - Country:US
Practice Address - Phone:435-752-7627
Practice Address - Fax:435-752-7802
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT324469-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT292486OtherDMBA
UT52082OtherPEHP
UT107007866101OtherIHC
UT870621775AN2OtherEDUCATORS MUTUAL INSURANC
UT870621775OtherTAX IDENTIFICATION #
UT870621775AN2OtherEDUCATORS MUTUAL INSURANC
UT870621775OtherTAX IDENTIFICATION #