Provider Demographics
NPI:1508259599
Name:SORENSEN, MARY (L AC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SORENSEN
Suffix:
Gender:F
Credentials:L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 SELBY AVE
Mailing Address - Street 2:STE G2
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-4508
Mailing Address - Country:US
Mailing Address - Phone:651-224-6678
Mailing Address - Fax:
Practice Address - Street 1:400 SELBY AVE
Practice Address - Street 2:STE G2
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-4508
Practice Address - Country:US
Practice Address - Phone:651-224-6678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-14
Last Update Date:2015-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1760171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist