Provider Demographics
NPI:1861501538
Name:SORENSEN, RICHARD LEE (PHD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:LEE
Last Name:SORENSEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 2ND AVE NE
Mailing Address - Street 2:SUITE 908
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701
Mailing Address - Country:US
Mailing Address - Phone:727-438-4237
Mailing Address - Fax:727-982-2454
Practice Address - Street 1:111 2ND AVE NE
Practice Address - Street 2:SUITE 908
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701
Practice Address - Country:US
Practice Address - Phone:727-438-4237
Practice Address - Fax:727-982-2454
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4438103T00000X
NM0773103T00000X
CO2906103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73700Medicare ID - Type Unspecified