Provider Demographics
NPI:1811982135
Name:STUPPY, JOHN BRYAN (LISW, LADAC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:BRYAN
Last Name:STUPPY
Suffix:
Gender:M
Credentials:LISW, LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2891 CLARK CT
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-5179
Mailing Address - Country:US
Mailing Address - Phone:505-930-4550
Mailing Address - Fax:505-474-4550
Practice Address - Street 1:2891 CLARK CT
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-5179
Practice Address - Country:US
Practice Address - Phone:505-930-4550
Practice Address - Fax:505-474-4550
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-61601041C0700X
NM3419101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM60759364Medicaid
NM53052552Medicaid