Provider Demographics
NPI:1942429451
Name:LUPCHO, THERESA D
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:D
Last Name:LUPCHO
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 1:6300 MOSELEY DIXON RD
Mailing Address - Street 2:APT. 206N
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31220-8400
Mailing Address - Country:US
Mailing Address - Phone:866-325-5434
Mailing Address - Fax:866-325-5340
Practice Address - Street 1:1050 CROWN POINTE PKWY
Practice Address - Street 2:SUITE 295
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-7707
Practice Address - Country:US
Practice Address - Phone:866-325-5434
Practice Address - Fax:866-325-5340
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002914103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical