Healthcare Provider Details

I. General information

NPI: 1720097132
Provider Name (Legal Business Name): NICHOLAS STEPHEN KOPP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 W FAYETTE ST
BALTIMORE MD
21201-1543
US

IV. Provider business mailing address

PO BOX 64277
BALTIMORE MD
21264-4277
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-2207
  • Fax: 410-328-9233
Mailing address:
  • Phone: 410-328-7037
  • Fax: 410-328-3311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number06528
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: