Healthcare Provider Details

I. General information

NPI: 1639129539
Provider Name (Legal Business Name): KERRY JOHN SOPOCI PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 01/19/2021
Certification Date: 01/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 N 6TH AVE E
DULUTH MN
55805-1952
US

IV. Provider business mailing address

220 N 6TH AVE E
DULUTH MN
55805-1952
US

V. Phone/Fax

Practice location:
  • Phone: 218-249-7000
  • Fax:
Mailing address:
  • Phone: 218-249-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLP4446
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: