Provider Demographics
NPI:1689607731
Name:SOPER, MARILYN C (PT)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:C
Last Name:SOPER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5N341 MARTINGALE DR
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:IL
Mailing Address - Zip Code:60103-3019
Mailing Address - Country:US
Mailing Address - Phone:630-830-3618
Mailing Address - Fax:630-830-3743
Practice Address - Street 1:5N341 MARTINGALE DR
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:IL
Practice Address - Zip Code:60103-3019
Practice Address - Country:US
Practice Address - Phone:630-830-3618
Practice Address - Fax:630-830-3743
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2232691OtherBLUE SHIELD PROVIDER #
IL11489061OtherCAQH PROVIDER ID