Healthcare Provider Details

I. General information

NPI: 1699106906
Provider Name (Legal Business Name): GEORGE STOUPAS PH.D., LCMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2013
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2594 REYNOLDA RD STE D
WINSTON SALEM NC
27106-4601
US

IV. Provider business mailing address

720 FINSBURY RD
WINSTON SALEM NC
27104-1715
US

V. Phone/Fax

Practice location:
  • Phone: 561-779-9598
  • Fax:
Mailing address:
  • Phone: 561-779-9598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number3904
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12159
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number16866
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: