=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497470496
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAULA POBLOCKI LAC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2022
-----------------------------------------------------
Last Update Date | 10/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2301 E EVESHAM RD STE 109
-----------------------------------------------------
City | VOORHEES
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08043-4502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-433-8615
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1306 ELM AVE
-----------------------------------------------------
City | HADDON TWP
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08107-1834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-230-3372
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number | 37AC00674400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------