Provider Demographics
NPI:1093719064
Name:SORENSEN, SHAWN RAE (PHD)
Entity type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:RAE
Last Name:SORENSEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1380
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-1380
Mailing Address - Country:US
Mailing Address - Phone:772-692-4410
Mailing Address - Fax:772-692-4508
Practice Address - Street 1:400 NW DIXIE HWY.
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994
Practice Address - Country:US
Practice Address - Phone:772-692-4410
Practice Address - Fax:772-692-4508
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-08
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0003676103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73403Medicare ID - Type Unspecified