Provider Demographics
NPI:1073264362
Name:KOPP, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:KOPP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 18TH AVE N STE 200
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-2253
Mailing Address - Country:US
Mailing Address - Phone:615-292-3661
Mailing Address - Fax:
Practice Address - Street 1:222 E BROADWAY BLVD STE 205
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37760-2837
Practice Address - Country:US
Practice Address - Phone:965-999-0601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-18
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN110131895OtherDRIVERS LICENSE