Provider Demographics
NPI:1134399926
Name:BOPP, MICHAEL J (LCSW)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:BOPP
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 GARDEN OF THE GODS RD
Mailing Address - Street 2:STE 104
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-4240
Mailing Address - Country:US
Mailing Address - Phone:719-598-3232
Mailing Address - Fax:
Practice Address - Street 1:300 GARDEN OF THE GODS RD
Practice Address - Street 2:STE 104
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-4240
Practice Address - Country:US
Practice Address - Phone:719-598-3232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-07
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9911571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO056672Medicaid