Provider Demographics
NPI:1417658436
Name:SODERGREN, BETHANY (OTR/L)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:SODERGREN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2530 RIDGETOP WAY
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33594-4223
Mailing Address - Country:US
Mailing Address - Phone:813-404-4878
Mailing Address - Fax:813-684-9985
Practice Address - Street 1:2530 RIDGETOP WAY
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33594-4223
Practice Address - Country:US
Practice Address - Phone:813-404-4878
Practice Address - Fax:813-684-9985
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-16
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT24041225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist