Healthcare Provider Details

I. General information

NPI: 1780738617
Provider Name (Legal Business Name): MARTHA JEAN SORENSEN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 09/28/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 MAJESTIC ST
FREDERICK CO
80504-6933
US

IV. Provider business mailing address

1300 N 17TH AVE
GREELEY CO
80631-9584
US

V. Phone/Fax

Practice location:
  • Phone: 970-347-2120
  • Fax:
Mailing address:
  • Phone: 970-347-2120
  • Fax: 970-300-3127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number2057
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY2057
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: