Provider Demographics
NPI:1386119238
Name:LARSEN, TRAVIS CODY
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:CODY
Last Name:LARSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:729 W 1450 S
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84663-4710
Mailing Address - Country:US
Mailing Address - Phone:435-590-5644
Mailing Address - Fax:
Practice Address - Street 1:360 S STATE ST STE 103
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-5745
Practice Address - Country:US
Practice Address - Phone:801-377-1117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7420337-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical