Provider Demographics
NPI:1114350782
Name:SOEDER, MARILYN ANN (LCSW-R)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:ANN
Last Name:SOEDER
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 NOEL RD
Mailing Address - Street 2:
Mailing Address - City:BROAD CHANNEL
Mailing Address - State:NY
Mailing Address - Zip Code:11693-1042
Mailing Address - Country:US
Mailing Address - Phone:718-945-2467
Mailing Address - Fax:
Practice Address - Street 1:621 ELMONT RD
Practice Address - Street 2:
Practice Address - City:ELMONT
Practice Address - State:NY
Practice Address - Zip Code:11003-4028
Practice Address - Country:US
Practice Address - Phone:516-502-2840
Practice Address - Fax:516-502-2841
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-18
Last Update Date:2013-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0474711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical