Provider Demographics
NPI:1982024501
Name:SHUPE, PHILIP (LCSW)
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:
Last Name:SHUPE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 LYNWOOD PL
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82604-3384
Mailing Address - Country:US
Mailing Address - Phone:801-597-5432
Mailing Address - Fax:
Practice Address - Street 1:1900 LYNWOOD PL
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82604-3384
Practice Address - Country:US
Practice Address - Phone:801-597-5432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-22
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLCSW-8211041C0700X
UT328017-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical