Provider Demographics
NPI:1801310123
Name:SORENSON, TERESA MARIE (LMT)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:MARIE
Last Name:SORENSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 BELLEVUE AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63143-1313
Mailing Address - Country:US
Mailing Address - Phone:314-875-0188
Mailing Address - Fax:
Practice Address - Street 1:2104 BELLEVUE AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MO
Practice Address - Zip Code:63143
Practice Address - Country:US
Practice Address - Phone:314-875-0188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012038878225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist