Provider Demographics
NPI:1538678966
Name:MEDEIROS LUPO, BRUNA
Entity Type:Individual
Prefix:
First Name:BRUNA
Middle Name:
Last Name:MEDEIROS LUPO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14139 SAPPHIRE BAY CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-7482
Mailing Address - Country:US
Mailing Address - Phone:407-529-7662
Mailing Address - Fax:
Practice Address - Street 1:14139 SAPPHIRE BAY CIR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-7482
Practice Address - Country:US
Practice Address - Phone:407-599-0043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-28
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH20596101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health