Provider Demographics
NPI:1689958225
Name:POPE, TYLICA SHANTE (CASAC T)
Entity Type:Individual
Prefix:
First Name:TYLICA
Middle Name:SHANTE
Last Name:POPE
Suffix:
Gender:F
Credentials:CASAC T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 THORN AVE
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-2600
Mailing Address - Country:US
Mailing Address - Phone:716-662-2040
Mailing Address - Fax:716-662-0019
Practice Address - Street 1:1235 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14209-2111
Practice Address - Country:US
Practice Address - Phone:716-884-5797
Practice Address - Fax:716-884-4938
Is Sole Proprietor?:No
Enumeration Date:2011-09-30
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor