Basic Information
| Provider Information | |||||||||
| NPI: | 1396000873 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SORENSON | ||||||||
| FirstName: | TRAVIS | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 807 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841033516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013610684 | ||||||||
| FaxNumber: | 8015818979 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 KOMAS DR | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841081215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015873483 | ||||||||
| FaxNumber: | 8015818979 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2012 | ||||||||
| LastUpdateDate: | 07/10/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 71071643501 | UT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.