Healthcare Provider Details

I. General information

NPI: 1114258688
Provider Name (Legal Business Name): SUSAN LYNNE POPEK-BOEVE CTRS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2010
Last Update Date: 01/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 CANNELLE CT
CANTON MI
48187-4587
US

IV. Provider business mailing address

143 CANNELLE CT
CANTON MI
48187-4587
US

V. Phone/Fax

Practice location:
  • Phone: 734-262-4786
  • Fax:
Mailing address:
  • Phone: 734-262-4786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number23270
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: