Provider Demographics
NPI:1154484020
Name:SORENSEN, MARY JO (MS, LMFT)
Entity Type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:SORENSEN
Suffix:
Gender:F
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2661 COUNTY HIGHWAY I
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729-5407
Mailing Address - Country:US
Mailing Address - Phone:715-723-5585
Mailing Address - Fax:
Practice Address - Street 1:2661 COUNTY HIGHWAY I
Practice Address - Street 2:
Practice Address - City:CHIPPEWA FALLS
Practice Address - State:WI
Practice Address - Zip Code:54729-5407
Practice Address - Country:US
Practice Address - Phone:715-723-5585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI709-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41006500Medicaid