Healthcare Provider Details

I. General information

NPI: 1245570308
Provider Name (Legal Business Name): CAITLYN BRIANNE SORENSEN-KOWALSKI PHD, LP, BCBA-LBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CAITLYN BRIANNE SORENSEN PHD, LP, BCBA-LBA

II. Dates (important events)

Enumeration Date: 02/26/2013
Last Update Date: 05/19/2020
Certification Date: 05/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18471 HAGGERTY RD
NORTHVILLE MI
48168-8513
US

IV. Provider business mailing address

910 HILLSIDE CT
YPSILANTI MI
48197-2138
US

V. Phone/Fax

Practice location:
  • Phone: 248-735-5928
  • Fax:
Mailing address:
  • Phone: 586-453-1297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301018402
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-13-13053
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: