Basic Information
| Provider Information | |||||||||
| NPI: | 1144831991 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SORENSEN | ||||||||
| FirstName: | SHAWN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1831 SW PARK AVE APT 306 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972013278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416319636 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2318 NE MARTIN LUTHER KING JR BLVD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972123715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033358611 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2020 | ||||||||
| LastUpdateDate: | 06/01/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 22-QMHA-R-2457 | OR | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | 21-05-10142 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.