Provider Demographics
NPI:1144321159
Name:SODERBERG, SANDRA (PT)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:SODERBERG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 DOUGLAS DR N
Mailing Address - Street 2:SUITE 203
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-3944
Mailing Address - Country:US
Mailing Address - Phone:763-525-9566
Mailing Address - Fax:763-544-2180
Practice Address - Street 1:2040 DOUGLAS DR N
Practice Address - Street 2:SUITE 203
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-3944
Practice Address - Country:US
Practice Address - Phone:763-525-9566
Practice Address - Fax:763-544-2180
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13532251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN641948OtherMEDICA
MN036J0SOOtherMN BCBS
MN173205Medicaid
MN289017800Medicaid
MN123593400OtherUS DEPT OF LABOR
MN173205Medicaid