Provider Demographics
NPI:1679291710
Name:SODERSTROM, STACIE MARIE (MA)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:MARIE
Last Name:SODERSTROM
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 S DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-0709
Mailing Address - Country:US
Mailing Address - Phone:605-209-8717
Mailing Address - Fax:
Practice Address - Street 1:1721 E AUSTIN ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57103-1500
Practice Address - Country:US
Practice Address - Phone:605-367-6140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist