Provider Demographics
NPI:1033936208
Name:SORRELLE, PATRICK AARON (EDS)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:AARON
Last Name:SORRELLE
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14422 WESTWIND LN
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-9382
Mailing Address - Country:US
Mailing Address - Phone:616-212-5040
Mailing Address - Fax:
Practice Address - Street 1:14422 WESTWIND LN
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-9382
Practice Address - Country:US
Practice Address - Phone:616-212-5040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-20
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISP0000303103TS0200X
MI2653730103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool