Provider Demographics
NPI:1053683813
Name:SODERHOLM, BRIAN (LMT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:SODERHOLM
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3536 N COMMERCIAL AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1308
Mailing Address - Country:US
Mailing Address - Phone:773-701-0675
Mailing Address - Fax:503-674-5005
Practice Address - Street 1:22400 SE STARK ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-2656
Practice Address - Country:US
Practice Address - Phone:503-491-5555
Practice Address - Fax:503-674-5005
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18501172M00000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist