Provider Demographics
NPI:1417203589
Name:SHUPE, ZULLY SOLEDAD (LCSW)
Entity type:Individual
Prefix:
First Name:ZULLY
Middle Name:SOLEDAD
Last Name:SHUPE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ZULLY
Other - Middle Name:SOLEDAD
Other - Last Name:GARCIA-DIAZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:1430 WILKINS CIR
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-1336
Mailing Address - Country:US
Mailing Address - Phone:307-237-9583
Mailing Address - Fax:
Practice Address - Street 1:1430 WILKINS CIR
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-1336
Practice Address - Country:US
Practice Address - Phone:307-237-9583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-26
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT327074-35011041C0700X
WYLCSW-8421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical