Provider Demographics
NPI:1942866009
Name:SODERSTROM, KARL ROBERT
Entity Type:Individual
Prefix:
First Name:KARL
Middle Name:ROBERT
Last Name:SODERSTROM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7017
Mailing Address - Country:US
Mailing Address - Phone:907-357-8784
Mailing Address - Fax:907-357-8781
Practice Address - Street 1:591 S KNIK GOOSE BAY RD
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8062
Practice Address - Country:US
Practice Address - Phone:907-313-1333
Practice Address - Fax:907-357-8781
Is Sole Proprietor?:No
Enumeration Date:2019-05-14
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)