Provider Demographics
NPI:1447707922
Name:GUPTILL, MARIE (LAC)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:GUPTILL
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 NEWELL AVE
Mailing Address - Street 2:#154
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596
Mailing Address - Country:US
Mailing Address - Phone:925-289-8431
Mailing Address - Fax:
Practice Address - Street 1:325 N WIGET LN STE 130
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-2435
Practice Address - Country:US
Practice Address - Phone:925-289-8431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 17010171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist