Healthcare Provider Details

I. General information

NPI: 1831364249
Provider Name (Legal Business Name): TRAVIS SCOTT MICKELSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2008
Last Update Date: 04/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DEPARTMENT OF PSYCHIATRY 30 N. 1900 E.
SLC UT
84132-0001
US

IV. Provider business mailing address

30 N 1900 E
SLC UT
84132-0002
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-7951
  • Fax: 801-581-5604
Mailing address:
  • Phone: 801-581-7951
  • Fax: 801-581-5604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number6837701-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: