Healthcare Provider Details

I. General information

NPI: 1629815782
Provider Name (Legal Business Name): ALYSSA VICTORIA KOPP LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2024
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12557 RAVENWOOD DR
CHARDON OH
44024-9009
US

IV. Provider business mailing address

12557 RAVENWOOD DR
CHARDON OH
44024-9009
US

V. Phone/Fax

Practice location:
  • Phone: 440-285-3568
  • Fax:
Mailing address:
  • Phone: 440-285-3568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2005521
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: