Healthcare Provider Details

I. General information

NPI: 1689320426
Provider Name (Legal Business Name): TARA LYNN CUPIT 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: 03/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 W CHELTEN AVE
PHILADELPHIA PA
19144-3803
US

IV. Provider business mailing address

220 W CHELTEN AVE
PHILADELPHIA PA
19144-3803
US

V. Phone/Fax

Practice location:
  • Phone: 215-310-7022
  • Fax: 267-281-1744
Mailing address:
  • Phone: 215-310-7022
  • Fax: 267-281-1744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW020980
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: