Provider Demographics
NPI:1376326579
Name:POUPARD, MITCHELL J
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:J
Last Name:POUPARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6444 E DUNBAR RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48161-5701
Mailing Address - Country:US
Mailing Address - Phone:734-735-5426
Mailing Address - Fax:
Practice Address - Street 1:15502 S TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-5520
Practice Address - Country:US
Practice Address - Phone:734-864-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician