Provider Demographics
NPI:1063461911
Name:LUPO, MAYRA (PT)
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:
Last Name:LUPO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MAYRA
Other - Middle Name:
Other - Last Name:RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:38 TELEGRAPH HILL RD
Mailing Address - Street 2:
Mailing Address - City:HOLMDEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07733-1449
Mailing Address - Country:US
Mailing Address - Phone:732-687-6851
Mailing Address - Fax:
Practice Address - Street 1:38 TELEGRAPH HILL RD
Practice Address - Street 2:
Practice Address - City:HOLMDEL
Practice Address - State:NJ
Practice Address - Zip Code:07733-1449
Practice Address - Country:US
Practice Address - Phone:732-687-6851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00289200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist