Provider Demographics
NPI:1215196118
Name:GATES-LUPTON, CHET (LCSW)
Entity Type:Individual
Prefix:MR
First Name:CHET
Middle Name:
Last Name:GATES-LUPTON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 W. STATE ST.
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-5474
Mailing Address - Country:US
Mailing Address - Phone:607-273-7494
Mailing Address - Fax:607-273-7484
Practice Address - Street 1:127 W STATE ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5474
Practice Address - Country:US
Practice Address - Phone:607-273-7494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY73-0735151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY73-073515OtherNY DEPT. OF HEALTH, SOCIAL WORK LICENSE
NY03676919Medicaid
NY03676919Medicaid