MEDICARE: PAUL POPERNIK M.A., L.C.P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor		IL

General Provider Information

NPI Number	:	1194940320
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAUL POPERNIK M.A., L.C.P.C.

Provider Business Mailing Address
First Line	:	1268 W ARDMORE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-3410
Country	:	US
Telephone Number	:	773-879-8831
Fax Number	:	773-635-0015

Provider Business Practice Location Address
First Line	:	413 W NORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60610-1117
Country	:	US
Telephone Number	:	773-879-8831
Fax Number	:	773-635-0015

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/14/2007
Last Update Date	:	07/09/2007

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