Provider Demographics
NPI:1639129539
Name:SOPOCI, KERRY JOHN (PSYD)
Entity Type:Individual
Prefix:MR
First Name:KERRY
Middle Name:JOHN
Last Name:SOPOCI
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 N 6TH AVE E
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1952
Mailing Address - Country:US
Mailing Address - Phone:218-249-7000
Mailing Address - Fax:
Practice Address - Street 1:220 N 6TH AVE E
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-1952
Practice Address - Country:US
Practice Address - Phone:218-249-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4446101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN797625900Medicaid
MN680001762Medicare ID - Type Unspecified