Healthcare Provider Details

I. General information

NPI: 1053637751
Provider Name (Legal Business Name): CAROL JOHNSON SORENSON M.DIV
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2010
Last Update Date: 04/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1224 LEGION WAY SE
OLYMPIA WA
98501-1655
US

IV. Provider business mailing address

1224 LEGION WAY SE
OLYMPIA WA
98501-1655
US

V. Phone/Fax

Practice location:
  • Phone: 360-790-3286
  • Fax:
Mailing address:
  • Phone: 360-790-3286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License NumberLH60129957
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: