Healthcare Provider Details

I. General information

NPI: 1932177722
Provider Name (Legal Business Name): BETHANY SUZANNE SORENSEN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

880 SR 6W
TUNKHANNOCK PA
18657
US

IV. Provider business mailing address

1 KELLY ST
MONTROSE PA
18801-1503
US

V. Phone/Fax

Practice location:
  • Phone: 570-836-7753
  • Fax:
Mailing address:
  • Phone: 570-470-4776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number026781
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number012237L
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11585
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: