1659517894 NPI number — PAUL E SORENSON LCSW

Table of content: PAUL E SORENSON LCSW (NPI 1659517894)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659517894 NPI number — PAUL E SORENSON LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SORENSON
Provider First Name:
PAUL
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659517894
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1114
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOREST GROVE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97116-4114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-608-8735
Provider Business Mailing Address Fax Number:
503-608-8735

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1909 MOUNTAIN VIEW LN
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
FOREST GROVE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97116-2894
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-608-8735
Provider Business Practice Location Address Fax Number:
503-608-8735
Provider Enumeration Date:
12/17/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  L4139 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 139431 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 139670 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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