Healthcare Provider Details

I. General information

NPI: 1275632937
Provider Name (Legal Business Name): SUSAN JANE SOREM L.S.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 E LOGAN ST STE B3
CALDWELL ID
83605
US

IV. Provider business mailing address

211 E LOGAN ST STE B3
CALDWELL ID
83605-4883
US

V. Phone/Fax

Practice location:
  • Phone: 620-221-9664
  • Fax:
Mailing address:
  • Phone: 208-454-1480
  • Fax: 800-983-3790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2510
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: