Provider Demographics
NPI:1881615110
Name:RUPP, MARLENA E (PSYD)
Entity type:Individual
Prefix:
First Name:MARLENA
Middle Name:E
Last Name:RUPP
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:661 MASSACHUSETTS AVE STE 14
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02476-5001
Mailing Address - Country:US
Mailing Address - Phone:617-674-0779
Mailing Address - Fax:339-707-0962
Practice Address - Street 1:661 MASSACHUSETTS AVE STE 14
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02476-5001
Practice Address - Country:US
Practice Address - Phone:617-674-0779
Practice Address - Fax:339-707-0962
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8593103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA030050Medicaid
MAW10533OtherBLUE CROSS BLUE SHIELD