Healthcare Provider Details

I. General information

NPI: 1780133637
Provider Name (Legal Business Name): NUPUR GUPTA PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2016
Last Update Date: 05/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3023 HAMAKER CT STE 600
FAIRFAX VA
22031-2241
US

IV. Provider business mailing address

3023 HAMAKER CT STE 600
FAIRFAX VA
22031-2241
US

V. Phone/Fax

Practice location:
  • Phone: 703-876-2788
  • Fax:
Mailing address:
  • Phone: 703-876-2788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number0810005322
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: