Provider Demographics
NPI:1609381094
Name:SODERHOLM, GREETA MAE (LICSW, LADC)
Entity Type:Individual
Prefix:MRS
First Name:GREETA
Middle Name:MAE
Last Name:SODERHOLM
Suffix:
Gender:F
Credentials:LICSW, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 GLEN RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-4131
Mailing Address - Country:US
Mailing Address - Phone:802-864-7467
Mailing Address - Fax:802-864-1619
Practice Address - Street 1:76 GLEN RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-4131
Practice Address - Country:US
Practice Address - Phone:802-864-7467
Practice Address - Fax:802-864-1619
Is Sole Proprietor?:No
Enumeration Date:2017-12-06
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101YA0400X
VT151.0125896101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)