Provider Demographics
NPI:1295957199
Name:SORENSEN, DIANE LYNN
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:LYNN
Last Name:SORENSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:LYNN
Other - Last Name:FITZGERALD-SWEDBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:19892 CHESAPEAKE LANE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646
Mailing Address - Country:US
Mailing Address - Phone:714-593-3003
Mailing Address - Fax:
Practice Address - Street 1:7368 CENTER AVENUE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647
Practice Address - Country:US
Practice Address - Phone:714-890-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMASS0019225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist