Provider Demographics
NPI:1265738785
Name:SORENSEN, AMMON (APC)
Entity type:Individual
Prefix:MR
First Name:AMMON
Middle Name:
Last Name:SORENSEN
Suffix:
Gender:M
Credentials:APC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:MOAB
Mailing Address - State:UT
Mailing Address - Zip Code:84532-2430
Mailing Address - Country:US
Mailing Address - Phone:435-259-6131
Mailing Address - Fax:435-259-5369
Practice Address - Street 1:198 E CENTER ST
Practice Address - Street 2:
Practice Address - City:MOAB
Practice Address - State:UT
Practice Address - Zip Code:84532-2430
Practice Address - Country:US
Practice Address - Phone:435-259-6131
Practice Address - Fax:435-259-5369
Is Sole Proprietor?:No
Enumeration Date:2011-01-31
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8149517-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health