Provider Demographics
NPI:1083374060
Name:SORENSON, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:SORENSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 W COPPERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:DUNLAP
Mailing Address - State:IL
Mailing Address - Zip Code:61525-9656
Mailing Address - Country:US
Mailing Address - Phone:309-339-0148
Mailing Address - Fax:
Practice Address - Street 1:409 W COPPERFIELD DR
Practice Address - Street 2:
Practice Address - City:DUNLAP
Practice Address - State:IL
Practice Address - Zip Code:61525-9656
Practice Address - Country:US
Practice Address - Phone:309-339-0148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-18
Last Update Date:2021-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator