=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477955771
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANE POPE LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2014
-----------------------------------------------------
Last Update Date | 09/18/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1019 FARMINGTON AVE
-----------------------------------------------------
City | BRISTOL
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06010-3955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-306-8192
-----------------------------------------------------
Fax | 860-231-6795
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 140 SYLVAN AVE
-----------------------------------------------------
City | WEST HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06107-1737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-521-6105
-----------------------------------------------------
Fax | 860-231-6795
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 008653
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------