Provider Demographics
NPI:1811886484
Name:SOPKO, LISA NICOLE (BA)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:NICOLE
Last Name:SOPKO
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2831 PROSPECT AVE E
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44115-2606
Mailing Address - Country:US
Mailing Address - Phone:216-579-1330
Mailing Address - Fax:216-771-5114
Practice Address - Street 1:2831 PROSPECT AVE E
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-2606
Practice Address - Country:US
Practice Address - Phone:216-579-1330
Practice Address - Fax:216-771-5114
Is Sole Proprietor?:No
Enumeration Date:2025-06-30
Last Update Date:2025-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHMC1234Medicaid