Provider Demographics
NPI:1699810457
Name:SORENSEN, ERIC KRISTEN (MS, LPC)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:KRISTEN
Last Name:SORENSEN
Suffix:
Gender:M
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64123 LIPPO RD
Mailing Address - Street 2:
Mailing Address - City:MARENGO
Mailing Address - State:WI
Mailing Address - Zip Code:54855-3506
Mailing Address - Country:US
Mailing Address - Phone:715-278-3335
Mailing Address - Fax:
Practice Address - Street 1:405 LAKE SHORE DR E
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-1837
Practice Address - Country:US
Practice Address - Phone:705-682-3523
Practice Address - Fax:715-682-3526
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3460 - 125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43597800Medicaid