Healthcare Provider Details

I. General information

NPI: 1093461840
Provider Name (Legal Business Name): HEIDI TUPA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2022
Last Update Date: 03/01/2022
Certification Date: 02/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 PAGE DR S STE 102A
FARGO ND
58103-3562
US

IV. Provider business mailing address

5 N TERRACE N
FARGO ND
58102-3815
US

V. Phone/Fax

Practice location:
  • Phone: 701-478-6604
  • Fax:
Mailing address:
  • Phone: 701-870-2677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4821
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: