Provider Demographics
NPI:1699338152
Name:LUPO, CARLY N (LCSW)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:N
Last Name:LUPO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 S ROSEMARY AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33401-6310
Mailing Address - Country:US
Mailing Address - Phone:561-246-5063
Mailing Address - Fax:
Practice Address - Street 1:700 S ROSEMARY AVE
Practice Address - Street 2:SUITE 204 OFC 101
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401
Practice Address - Country:US
Practice Address - Phone:561-246-5063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-19
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW162391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103557300Medicaid
FLM4MO2OtherBLUE CROSS BLUE SHIELD