Provider Demographics
NPI:1962460667
Name:SOPER, JOAN CROOK (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOAN
Middle Name:CROOK
Last Name:SOPER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-5031
Mailing Address - Country:US
Mailing Address - Phone:303-443-1223
Mailing Address - Fax:303-473-9153
Practice Address - Street 1:613 WALNUT ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-5031
Practice Address - Country:US
Practice Address - Phone:303-443-1223
Practice Address - Fax:303-473-9153
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1746103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07017460Medicaid
CO07017460Medicaid