Provider Demographics
NPI:1225505688
Name:LOGAN-SOPER, ALICIA JOHANNA (LMSW)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:JOHANNA
Last Name:LOGAN-SOPER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2940 MIDDLE RD
Mailing Address - Street 2:
Mailing Address - City:KEOKUK
Mailing Address - State:IA
Mailing Address - Zip Code:52632-2407
Mailing Address - Country:US
Mailing Address - Phone:319-795-5822
Mailing Address - Fax:
Practice Address - Street 1:1626 MORGAN ST STE 4
Practice Address - Street 2:
Practice Address - City:KEOKUK
Practice Address - State:IA
Practice Address - Zip Code:52632-3424
Practice Address - Country:US
Practice Address - Phone:319-249-5777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-24
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA092708104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker