Provider Demographics
NPI:1558405167
Name:SODERLUND, KEITH WILLIAM (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:WILLIAM
Last Name:SODERLUND
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 RICHMOND DR
Mailing Address - Street 2:
Mailing Address - City:ROMEOVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60446-5042
Mailing Address - Country:US
Mailing Address - Phone:708-642-6479
Mailing Address - Fax:
Practice Address - Street 1:339 RICHMOND DR
Practice Address - Street 2:
Practice Address - City:ROMEOVILLE
Practice Address - State:IL
Practice Address - Zip Code:60446-5042
Practice Address - Country:US
Practice Address - Phone:708-642-6479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012850225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist