Provider Demographics
NPI:1306271713
Name:TUPPER, SETH ELLIOT (LICSW)
Entity type:Individual
Prefix:
First Name:SETH
Middle Name:ELLIOT
Last Name:TUPPER
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5108 LAKESIDE AVE N
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55429-3734
Mailing Address - Country:US
Mailing Address - Phone:651-503-5780
Mailing Address - Fax:763-271-2707
Practice Address - Street 1:5108 LAKESIDE AVE N
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55429-3734
Practice Address - Country:US
Practice Address - Phone:651-503-5780
Practice Address - Fax:763-271-2707
Is Sole Proprietor?:No
Enumeration Date:2013-09-05
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN192551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical