Provider Demographics
NPI:1457859001
Name:COURTLAND SOPER, PAUL OWEN (LCSW-S, LISW-S, CCTP)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:OWEN
Last Name:COURTLAND SOPER
Suffix:
Gender:M
Credentials:LCSW-S, LISW-S, CCTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12501
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-0501
Mailing Address - Country:US
Mailing Address - Phone:513-207-4024
Mailing Address - Fax:
Practice Address - Street 1:3827 PAXTON AVE APT 641
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45209-2417
Practice Address - Country:US
Practice Address - Phone:513-207-4024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-29
Last Update Date:2021-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX618031041C0700X
COCSW.099269121041C0700X
OHI.18007861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX758615Medicaid