Captain Blake Soderstrom

Primary specialty

Mental Health CounselorTaxonomy code 101YM0800X

License

010908-01 Issued in NY

Practice address

PO Box 303
Brimley, MI 49715-0303

Phone

(906) 203-8354

NPI assigned

Sep 10, 2014

Last updated

Apr 5, 2024By the provider in NPPES

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1410307200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1712275200000",
    "number": "1699176677",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 303",
            "city": "BRIMLEY",
            "state": "MI",
            "postal_code": "497150303",
            "telephone_number": "906-203-8354"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "PO BOX 303",
            "city": "BRIMLEY",
            "state": "MI",
            "postal_code": "497150303",
            "telephone_number": "906-203-8354"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SODERSTROM",
        "first_name": "CAPTAIN",
        "middle_name": "BLAKE",
        "sole_proprietor": "YES",
        "sex": "U",
        "enumeration_date": "2014-09-10",
        "last_updated": "2024-04-05",
        "certification_date": "2024-04-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "MI",
            "license": "6401222931",
            "primary": false
        },
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "NY",
            "license": "010908-01",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Karen Joy Perkins, NP-C
• Beth Ann Pershinske, RDH
• Kamran A Qureshy, D.D.S
• Jade Seelye, LMSW
• Anthony Thomas Sheridan, MD
• Brooke Stover
• Lindsay Teeple, RDH
• Karen Louise Thompson, LPC
• Tara Lynn Tremblay
• Marvine Bernice Bedell Young

• Mental Health Counselor in Brimley, MI
• Providers in Brimley, MI by specialty
• Mental Health Counselor in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 5, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.