Healthcare Provider Details

I. General information

NPI: 1699486480
Provider Name (Legal Business Name): EMILY SHUPAK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2022
Last Update Date: 10/09/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

244 EAST AGATE AVE.
GRANBY CO
80446-5868
US

IV. Provider business mailing address

PO BOX 726
GRANBY CO
80446-0726
US

V. Phone/Fax

Practice location:
  • Phone: 970-241-6023
  • Fax:
Mailing address:
  • Phone: 970-241-6023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW.09933931
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: