Provider Demographics
NPI:1316404981
Name:SODERHAMN, TINA TOYOKO
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:TOYOKO
Last Name:SODERHAMN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8746 BLUE BALL RD
Mailing Address - Street 2:
Mailing Address - City:STEWARTSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17363-8057
Mailing Address - Country:US
Mailing Address - Phone:717-683-5351
Mailing Address - Fax:
Practice Address - Street 1:8746 BLUE BALL RD
Practice Address - Street 2:
Practice Address - City:STEWARTSTOWN
Practice Address - State:PA
Practice Address - Zip Code:17363-8057
Practice Address - Country:US
Practice Address - Phone:717-683-5351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-01
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD121961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical