Provider Demographics
NPI:1679071377
Name:SOPER, PAUL VINCENT (LCSW-R)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:VINCENT
Last Name:SOPER
Suffix:
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 HO PLAZA
Mailing Address - Street 2:CORNELL UNIVERSITY
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14853
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 HO PLAZA
Practice Address - Street 2:CORNELL UNIVERSITY
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14853
Practice Address - Country:US
Practice Address - Phone:607-255-5155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-28
Last Update Date:2018-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR079341-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical