MEDICARE: OLIVIA CUPP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1609277813
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLIVIA CUPP

Provider Business Mailing Address
First Line	:	1188 GANO AVE APT 110
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32073-4601
Country	:	US
Telephone Number	:	904-377-1514
Fax Number	:

Provider Business Practice Location Address
First Line	:	13904 GINGER CREEK BLVD
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32826-2505
Country	:	US
Telephone Number	:	904-377-1514
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2014
Last Update Date	:	09/07/2014

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Directions to “ OLIVIA CUPP ” Practice Location

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