Provider Demographics
NPI:1114990603
Name:RUPP, LARRY L (MSW, LCSW)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:L
Last Name:RUPP
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3040A WINDSOR CT
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-5555
Mailing Address - Country:US
Mailing Address - Phone:574-262-1088
Mailing Address - Fax:574-262-9516
Practice Address - Street 1:3040A WINDSOR CT
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-5555
Practice Address - Country:US
Practice Address - Phone:574-262-1088
Practice Address - Fax:574-262-9516
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-07
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004488A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200535020AMedicaid
IN232640Medicare PIN