Healthcare Provider Details

I. General information

NPI: 1215298559
Provider Name (Legal Business Name): RUSSELL DOUGLAS SORENSON PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2012
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 N MAIN STREET (REAR ENTRANCE)
RICHFIELD UT
84701
US

IV. Provider business mailing address

465 N 500 E
RICHFIELD UT
84701-2225
US

V. Phone/Fax

Practice location:
  • Phone: 435-287-4250
  • Fax:
Mailing address:
  • Phone: 435-287-4250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number11876179-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: