Provider Demographics
NPI:1821147638
Name:MARJORIE A SOPER P.C.
Entity Type:Organization
Organization Name:MARJORIE A SOPER P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARJORIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:SOPER
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW, CSW
Authorized Official - Phone:810-579-5757
Mailing Address - Street 1:4465 ATLAS RD
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423-8707
Mailing Address - Country:US
Mailing Address - Phone:810-579-5757
Mailing Address - Fax:810-579-5757
Practice Address - Street 1:12751 S SAGINAW ST
Practice Address - Street 2:STE 700
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-2751
Practice Address - Country:US
Practice Address - Phone:810-579-5757
Practice Address - Fax:810-579-5757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010638831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI38-1213512OtherTRICARE
MI800894156OtherBLUE CROSS OF MICHIGAN
MI037804OtherVALUE OPTIONS
MI39940OtherMAGELLAN
MI2053431OtherCIGNA
MI005=========01OtherCONNETICUT GENERAL
MI005=========01OtherCONNETICUT GENERAL