Provider Demographics
NPI:1689052268
Name:SORENSEN, NICOLE (MS, BCBA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SORENSEN
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4545 N SHEFFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:53211-1309
Mailing Address - Country:US
Mailing Address - Phone:414-299-0045
Mailing Address - Fax:
Practice Address - Street 1:4545 N SHEFFIELD AVE
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:WI
Practice Address - Zip Code:53211-1309
Practice Address - Country:US
Practice Address - Phone:414-299-0045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-14
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH11417264103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst