Provider Demographics
NPI:1528281524
Name:GUPTA, KIRAN - (LCSW -2678)
Entity type:Individual
Prefix:MRS
First Name:KIRAN
Middle Name:-
Last Name:GUPTA
Suffix:
Gender:F
Credentials:LCSW -2678
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2743 W IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-3915
Mailing Address - Country:US
Mailing Address - Phone:480-917-4586
Mailing Address - Fax:
Practice Address - Street 1:1405 N DOBSON RD
Practice Address - Street 2:SUITE 1
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-8594
Practice Address - Country:US
Practice Address - Phone:480-213-6502
Practice Address - Fax:480-726-0197
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-26781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ11451151OtherCAQH DATA SUMMARY
AZ102984Medicare ID - Type UnspecifiedLCSW