Provider Demographics
NPI:1932817004
Name:SORENSEN, GINA MARIE (BCBA)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:SORENSEN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 TETON PLZ STE 2
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6485
Mailing Address - Country:US
Mailing Address - Phone:208-360-9654
Mailing Address - Fax:
Practice Address - Street 1:2222 TETON PLZ STE 2
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6485
Practice Address - Country:US
Practice Address - Phone:208-360-9654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1-18-31788103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst