Provider Demographics
NPI:1740876796
Name:SOODSMA, LANEY MARIE (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:LANEY
Middle Name:MARIE
Last Name:SOODSMA
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:LANEY
Other - Middle Name:MARIE
Other - Last Name:KEMINK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:701 AUTUMN AVE
Mailing Address - Street 2:
Mailing Address - City:WAUPUN
Mailing Address - State:WI
Mailing Address - Zip Code:53963-1070
Mailing Address - Country:US
Mailing Address - Phone:920-960-4389
Mailing Address - Fax:
Practice Address - Street 1:1675 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53792-0002
Practice Address - Country:US
Practice Address - Phone:608-263-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5153-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist