Provider Demographics
NPI:1558441758
Name:SORGE, MARLIS (LCMHC)
Entity Type:Individual
Prefix:
First Name:MARLIS
Middle Name:
Last Name:SORGE
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 263
Mailing Address - Street 2:
Mailing Address - City:EAST THETFORD
Mailing Address - State:VT
Mailing Address - Zip Code:05043-0263
Mailing Address - Country:US
Mailing Address - Phone:802-356-1546
Mailing Address - Fax:
Practice Address - Street 1:11 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:VT
Practice Address - Zip Code:05060-1330
Practice Address - Country:US
Practice Address - Phone:802-728-4466
Practice Address - Fax:802-728-4197
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT068-0000415101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT2027288OtherCIGNA
VT14Y007415VT01OtherANTHEM
VT1010782Medicaid
VT39140OtherBLUE CROSS