Healthcare Provider Details

I. General information

NPI: 1063538791
Provider Name (Legal Business Name): MRS. DEIDRA ALEXANDER SORRELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 10/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1282 SMALLWOOD DR W STE #250
WALDORF MD
20603-4732
US

IV. Provider business mailing address

1282 SMALLWOOD DR W STE #250
WALDORF MD
20603-4732
US

V. Phone/Fax

Practice location:
  • Phone: 240-461-1305
  • Fax:
Mailing address:
  • Phone: 240-461-1305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPRC13819
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC2388
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: