Provider Demographics
NPI:1902294671
Name:POPOWITZ, CORAL (LGSW)
Entity Type:Individual
Prefix:
First Name:CORAL
Middle Name:
Last Name:POPOWITZ
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72351 PINE RIVER RD
Mailing Address - Street 2:
Mailing Address - City:WILLOW RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55795-3120
Mailing Address - Country:US
Mailing Address - Phone:218-372-3801
Mailing Address - Fax:
Practice Address - Street 1:72351 PINE RIVER RD
Practice Address - Street 2:
Practice Address - City:WILLOW RIVER
Practice Address - State:MN
Practice Address - Zip Code:55795-3120
Practice Address - Country:US
Practice Address - Phone:218-372-3801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN237901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical