Provider Demographics
NPI:1114351244
Name:SORUM, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:SORUM
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 1:19710 L ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68135-3709
Mailing Address - Country:US
Mailing Address - Phone:402-819-7510
Mailing Address - Fax:402-819-0915
Practice Address - Street 1:11840 NICHOLAS ST STE 205
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-4475
Practice Address - Country:US
Practice Address - Phone:402-819-7510
Practice Address - Fax:402-819-0915
Is Sole Proprietor?:No
Enumeration Date:2013-08-26
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE10057101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health