Healthcare Provider Details

I. General information

NPI: 1457574972
Provider Name (Legal Business Name): KIM RUTH KUPFER MEARES MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KIM RUTH KUPFER MFT

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 10/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27299 HOSPITAL ROAD SUITE 107
LAKE ARROWHEAD CA
92352
US

IV. Provider business mailing address

PO BOX 954
LAKE ARROWHEAD CA
92352
US

V. Phone/Fax

Practice location:
  • Phone: 909-383-7100
  • Fax: 909-890-0244
Mailing address:
  • Phone: 909-383-7100
  • Fax: 909-890-0244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC21299
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC27299
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: