Provider Demographics
NPI:1942434857
Name:SORENSEN, MISTY
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:SORENSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 CAMBRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-1823
Mailing Address - Country:US
Mailing Address - Phone:510-435-6789
Mailing Address - Fax:510-638-6807
Practice Address - Street 1:135 CAMBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-1823
Practice Address - Country:US
Practice Address - Phone:510-435-6789
Practice Address - Fax:510-638-6807
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-06
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA#41860106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist