Provider Demographics
NPI:1699158634
Name:SOPER FAMILY PSYCHIATRY MEDICAL GROUP
Entity type:Organization
Organization Name:SOPER FAMILY PSYCHIATRY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NIKI
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-445-4705
Mailing Address - Street 1:1836 CENTRAL AVE STE A
Mailing Address - Street 2:
Mailing Address - City:MCKINLEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95519-3667
Mailing Address - Country:US
Mailing Address - Phone:707-445-4705
Mailing Address - Fax:707-445-0581
Practice Address - Street 1:1836 CENTRAL AVE STE A
Practice Address - Street 2:
Practice Address - City:MCKINLEYVILLE
Practice Address - State:CA
Practice Address - Zip Code:95519-3667
Practice Address - Country:US
Practice Address - Phone:707-445-4705
Practice Address - Fax:707-445-0581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-08
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X, 103TC2200X
CAG59380261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty