Provider Demographics
NPI:1770790826
Name:LUPER, JAMES RUSSEL (MA, MFT)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:RUSSEL
Last Name:LUPER
Suffix:
Gender:M
Credentials:MA, MFT
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2665 SANTA ROSA AVE # 175
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-7683
Mailing Address - Country:US
Mailing Address - Phone:707-529-1247
Mailing Address - Fax:707-528-6238
Practice Address - Street 1:200 MONTGOMERY DR
Practice Address - Street 2:SUITE C
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-6633
Practice Address - Country:US
Practice Address - Phone:707-529-1247
Practice Address - Fax:707-528-6238
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC42057106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC42057OtherMARRIAGE& FAMILYTHERAPIST