Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | ||
Y | 103T00000X | Psychologist |
NPI | 1013525120 |
---|---|
Provider Name | Dr. Renato Popovic |
First Address | Fort Benning, GA 31905 |
Second Address | Columbus, GA 31906-1801 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/07/2020 |
Last Update Date | 06/01/2021 |