Healthcare Provider Details

I. General information

NPI: 1578795001
Provider Name (Legal Business Name): LORI LEANNE SOPER PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2009
Last Update Date: 08/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N MEDICAL DR
ASH GROVE MO
65604-1005
US

IV. Provider business mailing address

7789 N STATE HIGHWAY V
ASH GROVE MO
65604-8840
US

V. Phone/Fax

Practice location:
  • Phone: 417-751-2575
  • Fax:
Mailing address:
  • Phone: 417-751-3117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2001023613
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: