Provider Demographics
NPI:1942774021
Name:SAPURAM, VAIBHAV (LPA, HSP-PA)
Entity type:Individual
Prefix:
First Name:VAIBHAV
Middle Name:
Last Name:SAPURAM
Suffix:
Gender:M
Credentials:LPA, HSP-PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2205 NEW GARDEN RD APT 4617
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-1757
Mailing Address - Country:US
Mailing Address - Phone:512-850-3541
Mailing Address - Fax:
Practice Address - Street 1:1100 W MARKET ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27403-1830
Practice Address - Country:US
Practice Address - Phone:336-334-5662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-11
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5464103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty