Provider Demographics
NPI:1407214273
Name:SODERLUND, MICAHEL
Entity Type:Individual
Prefix:
First Name:MICAHEL
Middle Name:
Last Name:SODERLUND
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 1:5 RIVER RD
Mailing Address - Street 2:SUITE 142
Mailing Address - City:WILTON
Mailing Address - State:CT
Mailing Address - Zip Code:06897-4069
Mailing Address - Country:US
Mailing Address - Phone:203-529-5123
Mailing Address - Fax:
Practice Address - Street 1:5 RIVER RD
Practice Address - Street 2:SUITE 142
Practice Address - City:WILTON
Practice Address - State:CT
Practice Address - Zip Code:06897-4069
Practice Address - Country:US
Practice Address - Phone:203-529-5123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-08
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst