Provider Demographics
NPI:1154387843
Name:WITKIN LUPO, MARCY ANN
Entity type:Individual
Prefix:DR
First Name:MARCY
Middle Name:ANN
Last Name:WITKIN LUPO
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 1:3435 BRANDYWINE ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-5605
Mailing Address - Country:US
Mailing Address - Phone:858-270-0787
Mailing Address - Fax:858-274-5541
Practice Address - Street 1:3435 BRANDYWINE ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-5605
Practice Address - Country:US
Practice Address - Phone:858-270-0787
Practice Address - Fax:858-274-5541
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 17157103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0516034Medicaid