Provider Demographics
NPI:1821287210
Name:AGNEW, ELIZABETH SORENSEN (MFT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:SORENSEN
Last Name:AGNEW
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:SORENSEN
Other - Last Name:AGNEW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1210 S BASCOM AVE
Mailing Address - Street 2:SUITE 114
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-3543
Mailing Address - Country:US
Mailing Address - Phone:408-834-6985
Mailing Address - Fax:
Practice Address - Street 1:1210 S BASCOM AVE
Practice Address - Street 2:SUITE 114
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-3543
Practice Address - Country:US
Practice Address - Phone:408-834-6985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-22
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44792106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist