Healthcare Provider Details

I. General information

NPI: 1245433440
Provider Name (Legal Business Name): CHERYL SORENSEN BUPP PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1712 OLD SUMMERWOOD BLVD
SARASOTA FL
34232-2939
US

IV. Provider business mailing address

1712 OLD SUMMERWOOD BLVD
SARASOTA FL
34232-2939
US

V. Phone/Fax

Practice location:
  • Phone: 941-341-0933
  • Fax:
Mailing address:
  • Phone: 941-341-0933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY7314
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY002526
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number112930-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: