Provider Demographics
NPI:1144368010
Name:SODERQUIST, RANDY K (LCSW)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:K
Last Name:SODERQUIST
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 SOUTH MAIN
Mailing Address - Street 2:P.O. BOX 710
Mailing Address - City:FREDONIA
Mailing Address - State:AZ
Mailing Address - Zip Code:86022
Mailing Address - Country:US
Mailing Address - Phone:928-643-6000
Mailing Address - Fax:
Practice Address - Street 1:465 SOUTH MAIN
Practice Address - Street 2:
Practice Address - City:FREDONIA
Practice Address - State:AZ
Practice Address - Zip Code:86022
Practice Address - Country:US
Practice Address - Phone:928-643-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT131852-35011041C0700X
AZLCSW-126121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT131852-3501OtherSTATE LICENSE
AZLCSW-12612OtherSTATE