Provider Demographics
NPI:1821454026
Name:SORRELL, BEAU (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:BEAU
Middle Name:
Last Name:SORRELL
Suffix:
Gender:M
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:762 TRANSFER RD
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-4506
Mailing Address - Country:US
Mailing Address - Phone:651-900-2275
Mailing Address - Fax:
Practice Address - Street 1:762 TRANSFER RD
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-4506
Practice Address - Country:US
Practice Address - Phone:651-900-2275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-05
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN161961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical