Basic Information
| Provider Information | |||||||||
| NPI: | 1487741633 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOPER CONSULTING, PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | AT THE WELL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 7166 SUMMER OAK DRIVE | ||||||||
| Address2: | |||||||||
| City: | NOBLESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176262462 | ||||||||
| FaxNumber: | 3177741531 | ||||||||
| Practice Location | |||||||||
| Address1: | 12999 PARKSIDE DRIVE | ||||||||
| Address2: | |||||||||
| City: | FISHERS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175799356 | ||||||||
| FaxNumber: | 3177741531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2006 | ||||||||
| LastUpdateDate: | 07/16/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SOPER | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | ANTHONY | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3176262462 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOPER CONSULTING, PC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PH.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TM1800X | 57000107A | IN | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Mental Retardation & Developmental Disabilities | 103TB0200X | 20040752A | IN | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | 103TM1800X | 20040752A | IN | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Mental Retardation & Developmental Disabilities | 103TC0700X | 20040752A | IN | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.