Provider Demographics
NPI:1457504086
Name:SODERSTROM, GERALD D (PHD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:D
Last Name:SODERSTROM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 BRIAR LN
Mailing Address - Street 2:
Mailing Address - City:WHARTON
Mailing Address - State:TX
Mailing Address - Zip Code:77488-4304
Mailing Address - Country:US
Mailing Address - Phone:979-532-0900
Mailing Address - Fax:
Practice Address - Street 1:1212 BRIAR LN
Practice Address - Street 2:
Practice Address - City:WHARTON
Practice Address - State:TX
Practice Address - Zip Code:77488-4304
Practice Address - Country:US
Practice Address - Phone:979-532-0900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22059103T00000X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling