Provider Demographics
NPI:1760178479
Name:GUPTA, AMY AULICK (MDIV, MFT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:AULICK
Last Name:GUPTA
Suffix:
Gender:F
Credentials:MDIV, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9241 SW 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-4805
Mailing Address - Country:US
Mailing Address - Phone:567-203-2118
Mailing Address - Fax:
Practice Address - Street 1:9241 SW 2ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-4805
Practice Address - Country:US
Practice Address - Phone:567-203-2118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-14
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist