Provider Demographics
NPI:1972716116
Name:SODERBERG, ROBERT
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:SODERBERG
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 1:94 WARRENVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD CENTER
Mailing Address - State:CT
Mailing Address - Zip Code:06250-1228
Mailing Address - Country:US
Mailing Address - Phone:860-423-4161
Mailing Address - Fax:
Practice Address - Street 1:43 W MAIN ST
Practice Address - Street 2:
Practice Address - City:VERNON ROCKVILLE
Practice Address - State:CT
Practice Address - Zip Code:06066-3549
Practice Address - Country:US
Practice Address - Phone:860-871-8227
Practice Address - Fax:860-875-8299
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health