Provider Demographics
NPI:1134765167
Name:SORRELLS, BRENDA LEE (CO)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:LEE
Last Name:SORRELLS
Suffix:
Gender:F
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 S HERLONG AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-1089
Mailing Address - Country:US
Mailing Address - Phone:803-980-5080
Mailing Address - Fax:803-980-5083
Practice Address - Street 1:223 S HERLONG AVE STE 110
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1089
Practice Address - Country:US
Practice Address - Phone:803-980-5080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-25
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CFM02296224900000X
CO003119222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy Fitter