1770790826 NPI number — MR. JAMES RUSSEL LUPER MA, MFT

Table of content: MR. JAMES RUSSEL LUPER MA, MFT (NPI 1770790826)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770790826 NPI number — MR. JAMES RUSSEL LUPER MA, MFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUPER
Provider First Name:
JAMES
Provider Middle Name:
RUSSEL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MA, MFT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770790826
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2665 SANTA ROSA AVE # 175
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA ROSA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95407-7683
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-529-1247
Provider Business Mailing Address Fax Number:
707-528-6238

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 MONTGOMERY DR
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
SANTA ROSA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95404-6633
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-529-1247
Provider Business Practice Location Address Fax Number:
707-528-6238
Provider Enumeration Date:
05/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  MFC42057 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: MFC42057 . This is a "MARRIAGE& FAMILYTHERAPIST" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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