Provider Demographics
NPI:1629380225
Name:SODERBERG, JULIE LAUREN (BCABA)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:LAUREN
Last Name:SODERBERG
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2416 E WASHINGTON ST
Mailing Address - Street 2:SUITE G
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-4472
Mailing Address - Country:US
Mailing Address - Phone:309-662-5050
Mailing Address - Fax:630-303-9704
Practice Address - Street 1:2416 E WASHINGTON ST
Practice Address - Street 2:SUITE G
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-4472
Practice Address - Country:US
Practice Address - Phone:309-662-5050
Practice Address - Fax:630-303-9704
Is Sole Proprietor?:No
Enumeration Date:2010-07-12
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0-10-3827103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst