Provider Demographics
NPI:1497260392
Name:KOPACK, ALEXANDRA F (BCBA)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:F
Last Name:KOPACK
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 SHELBYVILLE RD STE 531
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-5132
Mailing Address - Country:US
Mailing Address - Phone:502-792-0236
Mailing Address - Fax:
Practice Address - Street 1:3901 CENTRAL PIKE STE 500
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:TN
Practice Address - Zip Code:37076-3431
Practice Address - Country:US
Practice Address - Phone:502-792-0236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-13
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0-17-8075106E00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst