Provider Demographics
NPI:1568482107
Name:SOTHERDEN, JOHN DAVID (LMSW)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:DAVID
Last Name:SOTHERDEN
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 LORRAINE AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-3230
Mailing Address - Country:US
Mailing Address - Phone:315-425-4400
Mailing Address - Fax:315-425-4406
Practice Address - Street 1:1031 E FAYETTE ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1022
Practice Address - Country:US
Practice Address - Phone:315-425-4400
Practice Address - Fax:315-425-4406
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY067183-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health