Provider Demographics
NPI:1659558971
Name:KOPA, ASHLEY BLAINE (PSYD)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:BLAINE
Last Name:KOPA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 936857
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-6857
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2131 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7407
Practice Address - Country:US
Practice Address - Phone:910-667-7000
Practice Address - Fax:910-815-5850
Is Sole Proprietor?:No
Enumeration Date:2008-01-29
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4515103T00000X
NC6864103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1659558971Medicaid
SCPSQ958Medicaid
NC6103826Medicaid
SCPC1254Medicaid
NCQ45799AMedicare PIN