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 1:14135 N CEDARBURG RD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53097-1416
Mailing Address - Country:US
Mailing Address - Phone:407-906-7301
Mailing Address - Fax:
Practice Address - Street 1:14135 N CEDARBURG RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53097-1416
Practice Address - Country:US
Practice Address - Phone:407-906-7301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-28
Last Update Date:2025-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH22195101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health