Provider Demographics
NPI:1417352006
Name:KOROMA, SORIE
Entity Type:Individual
Prefix:
First Name:SORIE
Middle Name:
Last Name:KOROMA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1280 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01603-1801
Mailing Address - Country:US
Mailing Address - Phone:508-774-1141
Mailing Address - Fax:
Practice Address - Street 1:1280 MAIN ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01603-1801
Practice Address - Country:US
Practice Address - Phone:508-774-1141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-26
Last Update Date:2014-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
MA394878101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No101Y00000XBehavioral Health & Social Service ProvidersCounselor