Basic Information
| Provider Information | |||||||||
| NPI: | 1770088221 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SABOURIN | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | TRAVIS | ||||||||
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| Credential: | LICSW, SUDP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 421 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990190421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092526446 | ||||||||
| FaxNumber: | 5092277070 | ||||||||
| Practice Location | |||||||||
| Address1: | 540 OAK CENTRE DR STE 205 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782583936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8448248775 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2018 | ||||||||
| LastUpdateDate: | 10/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | LW60774681 | WA | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | LW60774681 | WA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 107777 | TX | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.