Provider Demographics
NPI:1780794271
Name:GUPTA, MAMTA (MC)
Entity type:Individual
Prefix:MRS
First Name:MAMTA
Middle Name:
Last Name:GUPTA
Suffix:
Gender:F
Credentials:MC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16847 S 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85045-0718
Mailing Address - Country:US
Mailing Address - Phone:480-784-4644
Mailing Address - Fax:480-460-8011
Practice Address - Street 1:1730 S JENTILLY LN
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-5715
Practice Address - Country:US
Practice Address - Phone:480-784-4644
Practice Address - Fax:480-460-8011
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC1623101Y00000X, 101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health