Provider Demographics
NPI:1043563042
Name:LUPERON, ELLIE (LADC)
Entity Type:Individual
Prefix:MS
First Name:ELLIE
Middle Name:
Last Name:LUPERON
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:ELIAYNE
Other - Middle Name:
Other - Last Name:LUPERON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:191 E QUASSET RD
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:CT
Mailing Address - Zip Code:06281-3307
Mailing Address - Country:US
Mailing Address - Phone:617-785-8127
Mailing Address - Fax:
Practice Address - Street 1:20 STRATHMORE RD
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610-3414
Practice Address - Country:US
Practice Address - Phone:860-933-4783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-16
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101YA0400X, 101YM0800X
103TC1900X, 103TE1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & Sports
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1043563042Medicaid