=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558762443
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAROL POPA P.T.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2014
-----------------------------------------------------
Last Update Date | 09/10/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2167 KENSINGTON RD NE
-----------------------------------------------------
City | CARROLLTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44615-8626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-627-7651
-----------------------------------------------------
Fax | 330-627-6606
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 765 CRESTLAND AVE SE
-----------------------------------------------------
City | NORTH CANTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44720-3365
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-705-1060
-----------------------------------------------------
Fax | 330-830-6135
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number | PT006034
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------