Provider Demographics
NPI:1912434200
Name:POPPE, CAROL
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:POPPE
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 1:2550 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CENTRAL LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49622-9286
Mailing Address - Country:US
Mailing Address - Phone:703-479-6101
Mailing Address - Fax:
Practice Address - Street 1:10686 CRESTWOOD DR STE B
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-4407
Practice Address - Country:US
Practice Address - Phone:703-392-6166
Practice Address - Fax:703-392-6166
Is Sole Proprietor?:No
Enumeration Date:2017-05-17
Last Update Date:2017-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAOP-10-2017106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician