Provider Demographics
NPI:1053476309
Name:POPE, DAVID (LASAC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:POPE
Suffix:
Gender:M
Credentials:LASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 12TH PL STE 13
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-1433
Mailing Address - Country:US
Mailing Address - Phone:402-619-6419
Mailing Address - Fax:928-227-2967
Practice Address - Street 1:919 12TH PL STE 13
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-1433
Practice Address - Country:US
Practice Address - Phone:402-619-6419
Practice Address - Fax:928-227-2967
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLASAC-15150101YA0400X
NE358101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE23726797226Medicaid