Provider Demographics
NPI:1760709257
Name:POPPER, DOUGLAS L (LCSW)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:L
Last Name:POPPER
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 1:52 WESCOTT ST
Mailing Address - Street 2:
Mailing Address - City:FALMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04105-1625
Mailing Address - Country:US
Mailing Address - Phone:201-741-0102
Mailing Address - Fax:
Practice Address - Street 1:345 COTTAGE RD
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-3919
Practice Address - Country:US
Practice Address - Phone:201-741-0102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-23
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC055176001041C0700X
MELC140041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJBA526562OtherMEDICARE
NJ0021806Medicaid