Provider Demographics
NPI:1053581363
Name:SODERGREN, TIFFANY A (OTR/L)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:A
Last Name:SODERGREN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4056 N RICHMOND ST
Mailing Address - Street 2:1B
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-2634
Mailing Address - Country:US
Mailing Address - Phone:773-636-4291
Mailing Address - Fax:
Practice Address - Street 1:4056 N RICHMOND ST
Practice Address - Street 2:1B
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-2634
Practice Address - Country:US
Practice Address - Phone:773-636-4291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-04
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics