Provider Demographics
NPI:1851996763
Name:POPOVICH, SETH TYLER
Entity Type:Individual
Prefix:
First Name:SETH
Middle Name:TYLER
Last Name:POPOVICH
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 1:1713 SANDRA ST
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-1408
Mailing Address - Country:US
Mailing Address - Phone:217-390-4706
Mailing Address - Fax:
Practice Address - Street 1:404 BROOKVIEW DR, FARMER CITY
Practice Address - Street 2:
Practice Address - City:FRAMER CITY
Practice Address - State:IL
Practice Address - Zip Code:61842
Practice Address - Country:US
Practice Address - Phone:309-928-2118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant