MEDICARE: MR. RUSSELL POPE M.S., LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	3634-125	WI

General Provider Information

NPI Number	:	1538277322
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RUSSELL POPE M.S., LPC

Provider Business Mailing Address
First Line	:	830 N 109TH ST
Second Line	:	SUITE 26
City	:	WAUWATOSA
State	:	WI
Zip	:	53226-3754
Country	:	US
Telephone Number	:	262-278-0238
Fax Number	:

Provider Business Practice Location Address
First Line	:	830 N 109TH ST
Second Line	:	SUITE 26
City	:	WAUWATOSA
State	:	WI
Zip	:	53226-3754
Country	:	US
Telephone Number	:	262-278-0238
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	01/26/2015

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