Provider Demographics
NPI:1881241834
Name:LUPO, MICHAELA BROOKE (DPT)
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:BROOKE
Last Name:LUPO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2515 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-2319
Mailing Address - Country:US
Mailing Address - Phone:816-977-3870
Mailing Address - Fax:
Practice Address - Street 1:2519 COVE AVE
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-3910
Practice Address - Country:US
Practice Address - Phone:541-962-0830
Practice Address - Fax:541-975-2720
Is Sole Proprietor?:No
Enumeration Date:2019-08-23
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-06290225100000X
MO2019021794225100000X
OR63427225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist