Provider Demographics
NPI:1699176677
Name:SODERSTROM, CAPTAIN BLAKE
Entity type:Individual
Prefix:
First Name:CAPTAIN
Middle Name:BLAKE
Last Name:SODERSTROM
Suffix:
Gender:U
Credentials:
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 303
Mailing Address - Street 2:
Mailing Address - City:BRIMLEY
Mailing Address - State:MI
Mailing Address - Zip Code:49715-0303
Mailing Address - Country:US
Mailing Address - Phone:906-203-8354
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 303
Practice Address - Street 2:
Practice Address - City:BRIMLEY
Practice Address - State:MI
Practice Address - Zip Code:49715-0303
Practice Address - Country:US
Practice Address - Phone:906-203-8354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-10
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401222931101YM0800X
NY010908-01101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03505424Medicaid