Healthcare Provider Details

I. General information

NPI: 1366114068
Provider Name (Legal Business Name): ANA CUPP MSW, CSW-INTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2021
Last Update Date: 01/10/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11230 SW 90TH AVE
PORTLAND OR
97223-6423
US

IV. Provider business mailing address

11230 SW 90TH AVE
PORTLAND OR
97223-6423
US

V. Phone/Fax

Practice location:
  • Phone: 775-830-3568
  • Fax:
Mailing address:
  • Phone: 775-830-3568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number8442-S
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: