Provider Demographics
NPI:1215085691
Name:ANDRUS, MARLIN V (LCSW)
Entity type:Individual
Prefix:MR
First Name:MARLIN
Middle Name:V
Last Name:ANDRUS
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 1:1196 W SOUTH JORDAN PKWY STE A3
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-4604
Mailing Address - Country:US
Mailing Address - Phone:801-253-3169
Mailing Address - Fax:801-446-4499
Practice Address - Street 1:1196 W SOUTH JORDAN PKWY STE A3
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-4604
Practice Address - Country:US
Practice Address - Phone:801-253-3169
Practice Address - Fax:801-446-4499
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT133426-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1334263501OtherSTATE PROFESSIONAL LICENS