Provider Demographics
NPI:1750625166
Name:SORENSEN, SAMANTHA MARIE (PSYD, LP)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MARIE
Last Name:SORENSEN
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12331 MARMON ST NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-6280
Mailing Address - Country:US
Mailing Address - Phone:763-350-9032
Mailing Address - Fax:
Practice Address - Street 1:4601 EXCELSIOR BLVD STE 411
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-4977
Practice Address - Country:US
Practice Address - Phone:763-614-5060
Practice Address - Fax:763-614-5060
Is Sole Proprietor?:No
Enumeration Date:2012-11-26
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5556103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist