=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699158634
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOPER FAMILY PSYCHIATRY MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2015
-----------------------------------------------------
Last Update Date | 10/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1836 CENTRAL AVE STE A
-----------------------------------------------------
City | MCKINLEYVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95519-3667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-445-4705
-----------------------------------------------------
Fax | 707-445-0581
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1836 CENTRAL AVE STE A
-----------------------------------------------------
City | MCKINLEYVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95519-3667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-445-4705
-----------------------------------------------------
Fax | 707-445-0581
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | NIKI MOORE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 707-445-4705
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | G59380
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------