Provider Demographics
NPI:1275632937
Name:SOREM, SUSAN JANE (LSCSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:JANE
Last Name:SOREM
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 E LOGAN ST STE B3
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4883
Mailing Address - Country:US
Mailing Address - Phone:208-454-1480
Mailing Address - Fax:800-983-3790
Practice Address - Street 1:211 E LOGAN ST STE B3
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605
Practice Address - Country:US
Practice Address - Phone:620-221-9664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS25101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS2510OtherKANSAS LINCENSE
KS100098100AMedicaid
MD10819OtherLICENSE THROUGH 10/31.06