Provider Demographics
NPI:1093523375
Name:SODERHOLM, LILY
Entity type:Individual
Prefix:
First Name:LILY
Middle Name:
Last Name:SODERHOLM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10672 BAKER AVE NW
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-3046
Mailing Address - Country:US
Mailing Address - Phone:612-223-3452
Mailing Address - Fax:
Practice Address - Street 1:3007 HARBOR LN N STE 1200
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-5138
Practice Address - Country:US
Practice Address - Phone:612-439-4650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-19
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician