Provider Demographics
NPI:1427193903
Name:SHUPP, DIANE (MS, LPC)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:SHUPP
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8540 VERREE RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19111-1325
Mailing Address - Country:US
Mailing Address - Phone:215-342-7660
Mailing Address - Fax:215-701-3151
Practice Address - Street 1:8540 VERREE RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-1325
Practice Address - Country:US
Practice Address - Phone:215-342-7660
Practice Address - Fax:215-701-3151
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC000123101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional