Healthcare Provider Details

I. General information

NPI: 1861893562
Provider Name (Legal Business Name): NICOLE A CUPP-HERRING LPC, LISAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLE A CUPP LPC, LISAC

II. Dates (important events)

Enumeration Date: 09/12/2014
Last Update Date: 09/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 E. EARLL DR. SUITE 200
PHOENIX AZ
85012-2647
US

IV. Provider business mailing address

202 E. EARLL DR. SUITE 200
PHOENIX AZ
85012-2647
US

V. Phone/Fax

Practice location:
  • Phone: 602-599-5501
  • Fax: 602-599-5711
Mailing address:
  • Phone: 602-808-2800
  • Fax: 602-599-5711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLISAC-11079
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-12383
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: