Provider Demographics
NPI:1295511012
Name:POPOV, ALYSSE
Entity type:Individual
Prefix:
First Name:ALYSSE
Middle Name:
Last Name:POPOV
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 1:951 TECUMSEH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46201-1943
Mailing Address - Country:US
Mailing Address - Phone:317-654-7741
Mailing Address - Fax:
Practice Address - Street 1:1317 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46203-1940
Practice Address - Country:US
Practice Address - Phone:317-654-7741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-06
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0002302255A2300X
INBAF-APP23-000252255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer