Provider Demographics
NPI:1164662672
Name:SOPER, AMANDA GIBSON (MA OTR/L)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:GIBSON
Last Name:SOPER
Suffix:
Gender:F
Credentials:MA OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2999 CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-2761
Mailing Address - Country:US
Mailing Address - Phone:707-546-9160
Mailing Address - Fax:707-546-1338
Practice Address - Street 1:2999 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2761
Practice Address - Country:US
Practice Address - Phone:707-546-9160
Practice Address - Fax:707-546-1338
Is Sole Proprietor?:No
Enumeration Date:2009-02-23
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT9336225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist