Healthcare Provider Details

I. General information

NPI: 1568672178
Provider Name (Legal Business Name): LINDA AYSCUE GUPTA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 W. FRANKLIN ST.
RICHMOND VA
23284-2027
US

IV. Provider business mailing address

PO BOX 842027
RICHMOND VA
23284-2027
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-3405
  • Fax:
Mailing address:
  • Phone: 804-828-3405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904000812
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: