Provider Demographics
NPI:1982953295
Name:SORENSEN, RICHARD DERRICK (LCSW)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:DERRICK
Last Name:SORENSEN
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 1:899 W 1150 S
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-5421
Mailing Address - Country:US
Mailing Address - Phone:801-836-9504
Mailing Address - Fax:
Practice Address - Street 1:899 W 1150 S
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-5421
Practice Address - Country:US
Practice Address - Phone:801-836-9504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-31
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT295219-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical