Healthcare Provider Details

I. General information

NPI: 1083190284
Provider Name (Legal Business Name): KELLY SOPCHAK PH.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2018
Last Update Date: 07/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 OAK ST
CINCINNATI OH
45219-2504
US

IV. Provider business mailing address

411 OAK ST
CINCINNATI OH
45219-2504
US

V. Phone/Fax

Practice location:
  • Phone: 513-984-1800
  • Fax: 513-984-4909
Mailing address:
  • Phone: 513-984-1800
  • Fax: 513-984-4909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number36945
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number70461
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: