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NPI Code Detail

MEDICARE: MRS. GREETA MAE SODERHOLM LICSW, LADC

MEDICARE: MRS. GREETA MAE SODERHOLM LICSW, LADC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YA0400XAddiction (Substance Use Disorder) CounselorVT
2101YA0400XAddiction (Substance Use Disorder) Counselor151.0125896VT

General Provider Information

NPI Number : 1609381094
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. GREETA MAE SODERHOLM LICSW, LADC
Provider Business Mailing Address
First Line : 76 GLEN RD
Second Line :
City : BURLINGTON
State : VT
Zip : 05401-4131
Country : US
Telephone Number : 802-864-7467
Fax Number : 802-864-1619
Provider Business Practice Location Address
First Line : 76 GLEN RD
Second Line :
City : BURLINGTON
State : VT
Zip : 05401-4131
Country : US
Telephone Number : 802-864-7467
Fax Number : 802-864-1619
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/06/2017
Last Update Date : 12/06/2017

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