Provider Demographics
NPI:1255009635
Name:SORENSEN, SIOBHAN TULLY (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SIOBHAN
Middle Name:TULLY
Last Name:SORENSEN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 GREEN AVE
Mailing Address - Street 2:
Mailing Address - City:CASTLETON ON HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:12033-1407
Mailing Address - Country:US
Mailing Address - Phone:518-956-2302
Mailing Address - Fax:
Practice Address - Street 1:7395 W EASTMAN PL
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80227-5006
Practice Address - Country:US
Practice Address - Phone:303-730-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-01
Last Update Date:2021-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COSLP.0004566235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist