Healthcare Provider Details

I. General information

NPI: 1679437875
Provider Name (Legal Business Name): JUDITH G SORENSEN M.A., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2025
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 W BROADWAY AVE
MINNEAPOLIS MN
55411-2533
US

IV. Provider business mailing address

29660 SHOREVIEW CIR
LINDSTROM MN
55045-7029
US

V. Phone/Fax

Practice location:
  • Phone: 612-668-4200
  • Fax:
Mailing address:
  • Phone: 612-668-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number407013
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: