Provider Demographics
NPI:1366114068
Name:CUPP, ANA (MSW, CSW-INTERN)
Entity type:Individual
Prefix:
First Name:ANA
Middle Name:
Last Name:CUPP
Suffix:
Gender:F
Credentials:MSW, CSW-INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11230 SW 90TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6423
Mailing Address - Country:US
Mailing Address - Phone:775-830-3568
Mailing Address - Fax:
Practice Address - Street 1:11230 SW 90TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-6423
Practice Address - Country:US
Practice Address - Phone:775-830-3568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-30
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8442-S104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV00001142210Medicaid