Healthcare Provider Details

I. General information

NPI: 1972013282
Provider Name (Legal Business Name): SHANNON M SORENSON PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2017
Last Update Date: 05/04/2021
Certification Date: 04/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 5TH AVE STE 800
SEATTLE WA
98101-3136
US

IV. Provider business mailing address

1200 5TH AVE STE 800
SEATTLE WA
98101-3136
US

V. Phone/Fax

Practice location:
  • Phone: 610-349-4401
  • Fax:
Mailing address:
  • Phone: 610-349-4401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number10716
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: