Provider Demographics
NPI:1801428750
Name:SOPER, IAN MICHAEL
Entity type:Individual
Prefix:MR
First Name:IAN
Middle Name:MICHAEL
Last Name:SOPER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 SPRING LAKES DR APT 401
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31407-3509
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 LEMON GRASS CT
Practice Address - Street 2:
Practice Address - City:HILTON HEAD ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29928-3022
Practice Address - Country:US
Practice Address - Phone:843-341-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-09
Last Update Date:2020-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC.5749225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty