Provider Demographics
NPI:1750765293
Name:SORENSEN, MELISSA (LPMT, MT-BC)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:SORENSEN
Suffix:
Gender:F
Credentials:LPMT, MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4651 SEARS RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907-1793
Mailing Address - Country:US
Mailing Address - Phone:706-566-7414
Mailing Address - Fax:
Practice Address - Street 1:12060 ETRIS RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-1463
Practice Address - Country:US
Practice Address - Phone:678-701-1203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-15
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMUT000126225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist