Provider Demographics
NPI:1366442055
Name:SORYN, THRACE A (MA, LP)
Entity Type:Individual
Prefix:MS
First Name:THRACE
Middle Name:A
Last Name:SORYN
Suffix:
Gender:F
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2124 DUPONT AVE. SO.
Mailing Address - Street 2:SUITE G1
Mailing Address - City:MPLS
Mailing Address - State:MN
Mailing Address - Zip Code:55405
Mailing Address - Country:US
Mailing Address - Phone:612-374-2194
Mailing Address - Fax:
Practice Address - Street 1:2124 DUPONT AVE. SO.
Practice Address - Street 2:SUITE G1
Practice Address - City:MPLS
Practice Address - State:MN
Practice Address - Zip Code:55405
Practice Address - Country:US
Practice Address - Phone:612-374-2194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2562103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist