Healthcare Provider Details

I. General information

NPI: 1942967518
Provider Name (Legal Business Name): KANAN CUPP LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2021
Last Update Date: 11/18/2021
Certification Date: 11/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6060 N PARAMOUNT BLVD
LONG BEACH CA
90805-3711
US

IV. Provider business mailing address

6060 N PARAMOUNT BLVD
LONG BEACH CA
90805-3711
US

V. Phone/Fax

Practice location:
  • Phone: 562-634-9534
  • Fax:
Mailing address:
  • Phone: 562-634-9534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number97160
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: