Provider Demographics
NPI:1225819139
Name:POPE, CHARLENE E
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:E
Last Name:POPE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1565 W MAIN ST STE 425
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-2601
Mailing Address - Country:US
Mailing Address - Phone:469-337-6031
Mailing Address - Fax:
Practice Address - Street 1:1565 W MAIN ST STE 425
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-2601
Practice Address - Country:US
Practice Address - Phone:469-337-6031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT122822225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist