Provider Demographics
NPI:1174272231
Name:LOUTENSOCK, SASHA (CMHC INTERN)
Entity Type:Individual
Prefix:
First Name:SASHA
Middle Name:
Last Name:LOUTENSOCK
Suffix:
Gender:F
Credentials:CMHC INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1541 E 3045 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-3415
Mailing Address - Country:US
Mailing Address - Phone:801-503-6368
Mailing Address - Fax:
Practice Address - Street 1:2655 S LAKE ERIE DR STE B
Practice Address - Street 2:
Practice Address - City:WEST VALLEY
Practice Address - State:UT
Practice Address - Zip Code:84120-7351
Practice Address - Country:US
Practice Address - Phone:385-441-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-23
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INTERN101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health