Healthcare Provider Details

I. General information

NPI: 1851580179
Provider Name (Legal Business Name): LARRY SODERSTROM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2007
Last Update Date: 04/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 SAVIERS RD., #10
OXNARD CA
93033
US

IV. Provider business mailing address

7246 REMMET AVE
CANOGA PARK CA
91303-1531
US

V. Phone/Fax

Practice location:
  • Phone: 805-483-2253
  • Fax: 805-483-2255
Mailing address:
  • Phone: 818-206-0360
  • Fax: 818-206-0370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: