Healthcare Provider Details

I. General information

NPI: 1578972212
Provider Name (Legal Business Name): MS. MORGAN LEIGH SORENSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2014
Last Update Date: 01/10/2020
Certification Date: 01/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 COMMONWEALTH AVE
CHESTNUT HILL MA
02467-3800
US

IV. Provider business mailing address

140 COMMONWEALTH AVE
CHESTNUT HILL MA
02467-3858
US

V. Phone/Fax

Practice location:
  • Phone: 626-755-6578
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number11120
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: