Provider Demographics
NPI:1164209094
Name:LUPO, TARA CARMELINA (BSW)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:CARMELINA
Last Name:LUPO
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1358 HALF MOON RD
Mailing Address - Street 2:
Mailing Address - City:EL PRADO
Mailing Address - State:NM
Mailing Address - Zip Code:87529-7477
Mailing Address - Country:US
Mailing Address - Phone:505-699-9127
Mailing Address - Fax:
Practice Address - Street 1:1090 GOAT SPRINGS RD.
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571
Practice Address - Country:US
Practice Address - Phone:575-758-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program