Provider Demographics
NPI:1427343862
Name:POPOVICH, AMANDA ROSE
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:ROSE
Last Name:POPOVICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7110 MAGOUN AVENUE
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:IN
Mailing Address - Zip Code:46324
Mailing Address - Country:US
Mailing Address - Phone:219-688-6923
Mailing Address - Fax:
Practice Address - Street 1:7110 MAGOUN AVENUE
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46324
Practice Address - Country:US
Practice Address - Phone:219-688-6923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-14
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst