Healthcare Provider Details

I. General information

NPI: 1245527589
Provider Name (Legal Business Name): TIMOTHY MARK CUPPLES CIT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2011
Last Update Date: 07/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 MID CONTINENT PLZ 6TH FLOOR SUITE 602
WEST MEMPHIS AR
72301-1760
US

IV. Provider business mailing address

310 MID CONTINENT PLZ 6TH FLOOR SUITE 602
WEST MEMPHIS AR
72301-1760
US

V. Phone/Fax

Practice location:
  • Phone: 870-735-2499
  • Fax: 870-735-2496
Mailing address:
  • Phone: 870-735-2499
  • Fax: 870-735-2496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: