Healthcare Provider Details

I. General information

NPI: 1487066221
Provider Name (Legal Business Name): REBECCA SORENSON MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2014
Last Update Date: 03/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4590 SCOTT TRAIL
EAGAN MN
55122
US

IV. Provider business mailing address

1618 B CLEMSON DR
EAGAN MN
55122
US

V. Phone/Fax

Practice location:
  • Phone: 651-491-0714
  • Fax: 651-328-8254
Mailing address:
  • Phone: 651-491-0714
  • Fax: 651-328-8254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number19882
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: