Provider Demographics
NPI:1124264791
Name:SODERSTROM, MARGO ANGELA
Entity type:Individual
Prefix:
First Name:MARGO
Middle Name:ANGELA
Last Name:SODERSTROM
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 1:4343 WILLIAMSBOURGH DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-2006
Mailing Address - Country:US
Mailing Address - Phone:209-688-5233
Mailing Address - Fax:
Practice Address - Street 1:4343 WILLIAMSBOURGH DR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2006
Practice Address - Country:US
Practice Address - Phone:209-688-5233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-31
Last Update Date:2008-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CAIMF 56434106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)