Provider Demographics
NPI:1194940320
Name:POPERNIK, PAUL (MA, LCPC)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:POPERNIK
Suffix:
Gender:M
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1268 W ARDMORE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-3410
Mailing Address - Country:US
Mailing Address - Phone:773-879-8831
Mailing Address - Fax:773-635-0015
Practice Address - Street 1:413 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-1117
Practice Address - Country:US
Practice Address - Phone:773-879-8831
Practice Address - Fax:773-635-0015
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001635214Medicare UPIN
IL7335294Medicare UPIN