Basic Information
| Provider Information | |||||||||
| NPI: | 1043309586 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOPER | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | ANTHONY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D., HSPP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2813 STATE AVE | ||||||||
| Address2: | |||||||||
| City: | PANAMA CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324054325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176262462 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 340 MAGNOLIA CIR | ||||||||
| Address2: | |||||||||
| City: | TYNDALL AFB | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324035604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8502837511 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 03/20/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 20040752A | IN | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | PY9783 | FL | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.