Provider Demographics
NPI:1396270286
Name:SORENSON, MATTHEW
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:SORENSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 OASIS GRAND BLVD
Mailing Address - Street 2:#1004
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-1524
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3000 OASIS GRAND BLVD
Practice Address - Street 2:#1004
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33916-1524
Practice Address - Country:US
Practice Address - Phone:239-848-0004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-27
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW151551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical