Healthcare Provider Details

I. General information

NPI: 1205265188
Provider Name (Legal Business Name): AUDRA MARIA POPIK MACC, LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2013
Last Update Date: 05/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6758 WARRINGTON DR
NORTH OLMSTED OH
44070
US

IV. Provider business mailing address

6758 WARRINGTON DR
NORTH OLMSTED OH
44070-5052
US

V. Phone/Fax

Practice location:
  • Phone: 440-821-0424
  • Fax:
Mailing address:
  • Phone: 440-821-0424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC.1700191
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC.1700191
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.1700191
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.0024565
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: