Provider Demographics
NPI:1306070776
Name:LUPO, MELINDA TARYN (LCSW)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:TARYN
Last Name:LUPO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MELINDA
Other - Middle Name:TARYN
Other - Last Name:BLOOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:40 WYCKOFF STREET #3
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201
Mailing Address - Country:US
Mailing Address - Phone:216-403-4903
Mailing Address - Fax:
Practice Address - Street 1:3016 31ST STREET
Practice Address - Street 2:SUITE #1A
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11102
Practice Address - Country:US
Practice Address - Phone:216-403-4903
Practice Address - Fax:347-935-3936
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-13
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY08005011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical