MEDICARE: MRS. PALLAVI S GUPTA LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	LISAC10682	AZ
2	101YM0800X	Mental Health Counselor	LPC11968	AZ

General Provider Information

NPI Number	:	1821238866
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. PALLAVI S GUPTA LPC

Provider Business Mailing Address
First Line	:	12450 N RANCHO VISTOSO BLVD STE 100
Second Line	:
City	:	ORO VALLEY
State	:	AZ
Zip	:	85755-9567
Country	:	US
Telephone Number	:	520-661-4302
Fax Number	:

Provider Business Practice Location Address
First Line	:	12450 N RANCHO VISTOSO BLVD STE 100
Second Line	:
City	:	ORO VALLEY
State	:	AZ
Zip	:	85755-9567
Country	:	US
Telephone Number	:	520-661-4302
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/04/2009
Last Update Date	:	03/04/2009

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