Individual
CAPTAIN BLAKE SODERSTROM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
U
Contact information
Practice address
PO BOX 303, BRIMLEY, MI 49715-0303
(906) 203-8354
Mailing address
PO BOX 303, BRIMLEY, MI 49715-0303
(906) 203-8354
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
010908-01
NY
101YM0800X
Mental Health Counselor
6401222931
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
03505424
—
NY
Enumeration date
09/10/2014
Last updated
04/05/2024
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