Provider Demographics
NPI:1326410721
Name:SAMANTHA SORENSEN PSYD LP LLC
Entity Type:Organization
Organization Name:SAMANTHA SORENSEN PSYD LP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SORENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:763-350-9032
Mailing Address - Street 1:12331 LEVER ST NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-6643
Mailing Address - Country:US
Mailing Address - Phone:763-350-9032
Mailing Address - Fax:763-614-5060
Practice Address - Street 1:9289 CENTRAL AVE NE
Practice Address - Street 2:SUITE 401
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-3424
Practice Address - Country:US
Practice Address - Phone:763-614-5060
Practice Address - Fax:763-614-5060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-24
Last Update Date:2015-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5556103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty