Provider Demographics
NPI:1326040056
Name:SORENSON, PHILIP D (PT)
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:D
Last Name:SORENSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W3124 VAN ROY RD
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-3982
Mailing Address - Country:US
Mailing Address - Phone:920-968-1010
Mailing Address - Fax:920-968-1012
Practice Address - Street 1:W3124 VAN ROY RD
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-3982
Practice Address - Country:US
Practice Address - Phone:920-968-1010
Practice Address - Fax:920-968-1012
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3895225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40245500Medicaid
WI5567490001Medicare NSC
001086443Medicare ID - Type Unspecified