Provider Demographics
NPI:1134421902
Name:SOREN R. EKSTROM, INC.
Entity type:Organization
Organization Name:SOREN R. EKSTROM, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SOREN
Authorized Official - Middle Name:R
Authorized Official - Last Name:EKSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:617-923-6086
Mailing Address - Street 1:29 CHESTER ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-4002
Mailing Address - Country:US
Mailing Address - Phone:617-923-6086
Mailing Address - Fax:
Practice Address - Street 1:29 CHESTER ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-4002
Practice Address - Country:US
Practice Address - Phone:617-923-6086
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-29
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3505103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty