Basic Information
| Provider Information | |||||||||
| NPI: | 1649872649 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | ERICA | ||||||||
| MiddleName: | PATRICIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1234 S 580 W | ||||||||
| Address2: | |||||||||
| City: | OREM | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840583321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163018516 | ||||||||
| FaxNumber: | 0000000000 | ||||||||
| Practice Location | |||||||||
| Address1: | 69010 HIGHLAND DR #1, COTTONWOOD HEIGHTS, UT 84121 | ||||||||
| Address2: | |||||||||
| City: | COTTONWOOD HEIGHTS | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841210000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019354171 | ||||||||
| FaxNumber: | 0000000000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2020 | ||||||||
| LastUpdateDate: | 11/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | NA | UT | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 0000000 | 01 | NON MEDICAID IDENTIFIED | OTHER |