Provider Demographics
NPI:1770050650
Name:LUPAMBO, MWICHE
Entity type:Individual
Prefix:MS
First Name:MWICHE
Middle Name:
Last Name:LUPAMBO
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 1:232 2ND AVE S
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98032-5862
Mailing Address - Country:US
Mailing Address - Phone:253-859-0300
Mailing Address - Fax:
Practice Address - Street 1:4606 S 170TH ST
Practice Address - Street 2:
Practice Address - City:SEATAC
Practice Address - State:WA
Practice Address - Zip Code:98188-3254
Practice Address - Country:US
Practice Address - Phone:218-259-0448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-29
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMG60311142106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist