Provider Demographics
NPI:1932504685
Name:SORG, TERRA (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:TERRA
Middle Name:
Last Name:SORG
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4467 161ST LN NE
Mailing Address - Street 2:
Mailing Address - City:HAM LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55304-5908
Mailing Address - Country:US
Mailing Address - Phone:612-205-2668
Mailing Address - Fax:
Practice Address - Street 1:821 RAYMOND AVE STE 300
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1525
Practice Address - Country:US
Practice Address - Phone:612-205-2668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-23
Last Update Date:2024-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN248461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1023258662Medicaid