Provider Demographics
NPI:1932270345
Name:SORENSEN, MARK (PHD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SORENSEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 KENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02459-1421
Mailing Address - Country:US
Mailing Address - Phone:617-332-5382
Mailing Address - Fax:
Practice Address - Street 1:30 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02461-1527
Practice Address - Country:US
Practice Address - Phone:617-965-6283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3640103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW03686Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER