Provider Demographics
NPI:1144486895
Name:ANSON, MARC LEE (LCSW)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:LEE
Last Name:ANSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1141 W 3090 S
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:UT
Mailing Address - Zip Code:84075-9083
Mailing Address - Country:US
Mailing Address - Phone:801-791-2073
Mailing Address - Fax:
Practice Address - Street 1:1747 HERITAGE LN STE B101
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:UT
Practice Address - Zip Code:84075-8546
Practice Address - Country:US
Practice Address - Phone:385-439-1926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-01
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5780998-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT876000308007Medicaid