Provider Demographics
NPI:1518004753
Name:SORENSON, CYNTHIA D (PHD)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:D
Last Name:SORENSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 SHARP RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53185-5214
Mailing Address - Country:US
Mailing Address - Phone:262-534-7297
Mailing Address - Fax:262-534-7257
Practice Address - Street 1:1701 SHARP RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:WI
Practice Address - Zip Code:53185-5214
Practice Address - Country:US
Practice Address - Phone:262-534-7297
Practice Address - Fax:262-534-7257
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2449057103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39151400Medicaid
WI000000122-0022Medicare ID - Type UnspecifiedMED PART B