Provider Demographics
NPI:1740322031
Name:SOPER, PAMELA KAE (LCSW)
Entity type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:KAE
Last Name:SOPER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 N RANDOLPH ST
Mailing Address - Street 2:SUITE 404
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3949
Mailing Address - Country:US
Mailing Address - Phone:217-351-5188
Mailing Address - Fax:
Practice Address - Street 1:206 N RANDOLPH ST
Practice Address - Street 2:SUITE 404
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-3949
Practice Address - Country:US
Practice Address - Phone:217-351-5188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01032067OtherBLUE CROSS BLUE SHIELD