Provider Demographics
NPI:1891854113
Name:KOPP, THOMAS GREGORY (PSYD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:GREGORY
Last Name:KOPP
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:T
Other - Middle Name:GREGORY
Other - Last Name:KOPP
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:350 EL MOLINO BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-2915
Mailing Address - Country:US
Mailing Address - Phone:575-525-8500
Mailing Address - Fax:575-524-5968
Practice Address - Street 1:350 EL MOLINO BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-2915
Practice Address - Country:US
Practice Address - Phone:575-525-8500
Practice Address - Fax:575-524-5968
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM456103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMN0260Medicaid
NMN249OtherBCBS
NM201005385OtherPRESBYTERIAN